APTA Delegate 101

With my new pal Jenny Jordan

I was watching Gilmore Girls re-runs one evening in November 2021 when an email notification popped up on my screen from Dr. Jenny Jordan, Physical Therapist, Professor in the Eastern Washington University PT Program, former Chief and current Delegate for APTA (American Physical Therapy Association) Washington, and - I would soon learn - incredible human being. Jenny's email asked if I would be willing to discuss an appointment to a one-year term as an Alternate Delegate representing APTA Washington.  

With my long-time pal, Maryclaire Capetta

I've been an APTA member since starting PT School in 2011, but despite how much money I've spent on membership, at the time of Jenny's message, I really couldn't explain what the APTA did. I joined as a student when it was compulsory, and I maintained membership because it discounted board certification and allowed me networking opportunities that I occasionally took advantage of.  Also, it felt like it was the right thing to do, supporting the leaders of my profession.  I knew that Delegates existed and that they worked on making changes that impact the physical therapy profession from a nation-wide perspective, but I had never given any thought to being a representative myself.  One of my Professors in PT School, Maryclaire Capetta, now a long-time friend, has been a Delegate in Connecticut for many years. She took me to a Delegation event at CSM in Chicago in 2012, which was my first glance at the politics of PT.  Over my eigght years attending PT Pub Night events living in Seattle, I've gotten to know several of our local Delegates including some who are good friends. All of this to say - I knew Delegates existed.  I did not know how they came to be in their role, what they did, or why I would ever want to be one.

We set up a time to chat and Jenny explained the responsibilities and the time commitment and asked if I wanted to join for a one-year term. Washington had enough elected Delegates to serve two-year terms, but because our group is pretty large, if the time came to vote and someone wasn't available, we needed to have alternates to step in. Our Alternate Delegates participate in all the regular meetings along with the rest of the Delegation and contribute to the discussions and can work on developing policies, but they do not have the ability to vote unless an elected Delegate is unavailable.  The usual process to be chosen for the Alternate Delegate spots is to be the next highest vote getter on the ballot after the votes are counted. Unfortunately, there weren't enough names on the ballot for the 2022 cycle to fill the Alternate slots. I said yes, and after one year of a much deeper dive into what the APTA does, how new policies are formed, and learning about the problems the Association and the Profession faces, I'm here to share some of that with you.

First and foremost, I want to be very clear: I’m really new at this and there are many others who have been working in leadership roles for far longer who know much more about the APTA.  I was just recently elected into a two-year term as a Delegate for the 2023 and 2024 House of Delegates Cycles and have only attended one House of Delegates meeting so far. This is my understanding of things and my experience- it’s true to the best of my knowledge.  If I'm wrong, for sure someone should tell me!  

Let’s talk about Delegations first.

I've come to understand the Delegation to be a little like the US Congress, but instead of two separate chambers, ours are combined.  In US politics, there’s the Senate with two Senators from each state, and the House of Representatives, with number of representatives based on population of the state. In the APTA, all the Academies/Sections (think specialty areas of practice: acute care, pediatrics, geriatrics, orthopedics, etc) have two votes, and the Chapters (each state and Washington DC) have representatives based on the number of APTA members in that state.  Link to see full apportionment list by state, but here's a tiny snapshot of the top of the list:

Just like in American politics, states with more members have a bigger impact on the direction of the profession. States also have Alternates, which was my role, which are included in all the regular meetings, but don’t vote unless one of the elected delegates isn’t available. According to this document, there were 73,525 members in the APTA as of July 2021. This includes professional Physical Therapists and Physical Therapist Assistants, but not our student members, which push our total membership closer to 100,000. I was curious, so I looked for comparisons from other large medical associations and found that the American Medical Association has about 250,000 members, the American Dental Association has about 160,000 members, and AOTA, the American Occupational Therapy Association, lists about 65,000 members. 

Delegates meet with their Delegations throughout the year, led by their Chiefs. Regionally, Chiefs gather at regular intervals to discuss what’s happening across the country and what groups are working on at their local levels. The whole group meets annually at the House of Delegates, led by a Speaker of the House. The purposes of the House of Delegates meetings are 1) to elect new officers to the Board for the APTA, 2) to debate and vote on motions to move the profession forward, 3) for the elected leaders of the Association to have opportunities to meet, network, recognize individuals who have done impactful work, and 4) learn about different topics related to leadership.  This year, House of Delegates was embedded into an entire Leadership Conference, including many students as well as the Delegates. If you want to find out who your Delegates are, you can search the rosters here. 

I've said Delegates too many times already...  So how about some of the work they're doing? How does a motion come to be?  In January, the elected representatives from Washington met for our regularly scheduled monthly meeting to brainstorm ideas for work that we would like to see done by the Association.  We came up with several possible ideas and broke off into smaller groups to do some early research on the topics, come up with basic rationale for why we felt the concepts were important, and then expand the concepts into more detail at subsequent meetings.  The group voted on each idea, deciding which ones we wanted to dedicate our time and effort to, and which ones did not seem to be optimal for continued work.  This year, Washington presented three motion concepts to the House of Delegates and members of our group spent about six months working on them. 

An important piece of motion development is collaboration with other Academies or Chapters.  Consider that priorities around the country differ, payment models are not the same state by state, challenges to patient care practices differ depending on the Academies and variation between settings.  So early on, we identified potential groups that might be helpful as co-makers to the motions, helping to develop statements in support, who would likely want to pursue the same outcomes.  For our three motions, we collaborated with three different Chapters and one Academy as co-makers.  I primarily worked on RC 16-22, APTA as an LGBTQIA+ inclusive organization in collaboration with the Academy of Leadership and Innovation and PT Proud, which ultimately passed by over 90% vote.  

There's a whole process that the Chief facilitates to take the motions and escalate them up the chain of the APTA to be reviewed by a Reference Committee (which I think makes sure we're not going to violate any of our own previous rules and regulations or any laws, and gives input on the language being used) as well as sharing the motions with the rest of the country's delegates for feedback and discussion.  Washington's Chief, Murray Maitland, had to do a lot of work to get our three motions reviewed and heard on the floor. Over time, updated versions are developed and the content and language can change until the minute it is debated on the floor of the House and voted on.  

This year the House had 22 motions up for debate, but did not end up completing the whole list, running out of time.  The whole operation follows Roberts Rules and Parliamentary Procedure and stays on time with an agenda - which can be amended - but which this year's delegation voted not to amend to increase the time.  It was really unfortunate because there are some really important issues that were waiting to be voted upon.  I pretty much live-tweeted the House of Delegates so you can find a barrage of my tweets from August 14th and 15th from me sharing how things were progressing as we worked through debate and voting.  

I could probably write a small book about my experience at the House of Delegates, but since I will

 Bringing RC 16-22 to the floor for vote

now have two more to attend in the future, I think I'll save those for another day.  It was incredibly exciting working on an important motion that will hopefully improve Diversity, Equity, and Inclusion in our profession.  It was amazing meeting the physical therapists who have worked so hard to shape our profession for many years - and who the leaders of tomorrow might be.  I hope this is helpful to anyone who is considering APTA membership. Know that your state IS impacted by your membership and that a small group of new members could influence how many delegates your local group has to vote on issues in the future.  I also hope that it helps more people to understand what APTA Delegates do - so if you have an issue, APTA member or not, find your local Delegates and share your concerns so they can try to help.  Feel free to reach out to me if you're looking for ways to get involved!

The CALU Summit

Hey followers!  It's been a little while. How are you all doing?  Have you checked in with yourself to make sure you're taking time to relax, breathe, eat, sleep, and move?  If you have any nurses or doctors in your life, send them a nice note or bring them a coffee because they're working so much harder than they've ever had to.

Today I'm writing about the CALU Summit which I recently attended virtually.  The name CALU comes from the combination of Clinical Athlete and The Level Up Initiative. I've attended A LOT of continuing education courses over the past seven years as a PT and I'm certain this was the most fun learning I've ever experienced.  This was my first CALU Summit - their second time holding the event - but I have interacted with both groups in different ways for many years.  In the past, I went through the Level Up Initiative's mentorship program and then served as a mentor and am planning to again. I've previously written about them here. Clinical Athlete puts out podcast episodes that I've listened to and I've participated in some of their journal clubs.  Both groups have loads of social media worth following and are led by super smart physical therapists who believe in educating healthcare providers.  These two networks have impacted my patient care and helped me develop as a physical therapist. In my opinion, both groups are MUST FOLLOW accounts for physical therapists, strength coaches, athletic trainers, and any new grad healthcare provider - but would also be great options for sport coaches, athletes, and parents of athletes to check out! (Specific names to search for on Instagram include: @thelevelupinitiative @clinicalathlete @zakgabor.dpt @stephallen.dpt @quinn.henochdpt @jared.unbreakablestrength @rebuild_stronger - sorry if I missed anyone!) Here are some of my favorite take-aways from the Summit! (Disclaimer - this is what stood out to me, not direct quotations.)

Each day of the Summit had a theme: barbell athletes, endurance athletes, and ACL rehabilitation, with two presentations on each topic.  There was key focus on the biopsychosocial approach, communication, and on case study discussion. The keynote speaker kicking off the weekend was Erik Meira, The Science PT whose talk was "The Socratic Therapist." He quoted Socrates, "What I do not know, I do not think I know," starting us off with philosophical thinking and the understanding that healthcare providers who dedicate themselves to continuous learning are simply working to be "Less Wrong" every day.  None of us can really ever know for certain that what we're doing is the absolute best option for our patients, but with scientific experimentation and consideration of evidence, we can get closer to being right by increasing our knowledge. There were several moments during the course where I had the chance to think back to how my practice has evolved based on what I've learned.  This was the first instance of that reflection. Erik offers his own courses, both online and in person, one of which I'm about to start after I finish ACL Study Day (there aren't enough hours in the day!).  Definitely check him out.  (IG: @erikmeirapt)

Day 1: The Barbell Athlete:  

Presenter  #1 was Stefi Cohen - a super strong woman, competitive powerlifter, and physical therapist who founded the Hybrid Performance Method and coauthored the book Back In Motion.  She described her experience with a low back injury with consultations from from both Stu McGill and Greg Lehman - well known Canadian practitioners in the rehab space who have different approaches despite Greg having been a student of Stu's.  Stefi shared the outcomes and her take-away understanding from those providers.  She discussed that she spent four hours doing special tests with Stu McGill and ultimately was in a lot of pain for an extended period of time after her examination and that his approach to avoid certain movements and take time away from her sport didn't resonate with her - but that she appreciated his estimate on the amount of time it would take for her to get back to her previous level of competition.  His timeline turned out to be fairly accurate, from what Stefi described.  In contrast, she saw Greg Lehman virtually and found a rehab approach that aligned with her own beliefs and with the understanding of finding safety in movement and progressing from there.  

Presenter #2 was Quinn Henoch - founder of Clinical Athlete, competitive weight lifter, podcaster, presenter, coach, and physical therapist.  Quinn's talk, "A process to help barbell sport athletes get back to those gainzzzzz" described a roadmap to coach/rehab barbell athletes.  The path has bookends starting from where an athlete's current physical function is and working towards what's "done" for them. Initiation of the plan requires the physical therapist (or coach) to define their role and set expectations based on the stated goals of the athlete.  Completion of training needs to be valuable to the patient - not the therapist.  For some clients, "done" with a program is able to complete 1 activity or task or be able to tolerate a certain position or load.  When an athlete has a specific goal in mind, we as practitioners should understand the target and guide to that.  It's just like all the kids are saying these days: "Understand the assignment."  It doesn't matter what I think "done" should be for my patients - if they haven't reached their goal, I've missed the mark.  I definitely have fallen into this trap in the clinic where I've wanted someone to be capable of doing something that they're not interested in doing.  Or, right now, I'm working with a teenager whose parent wants them to start running after an injury, but the kid wants nothing to do with running at all. Done for this patient is walking, going up and down the stairs, and participating in PE without pain.  The approach has to fit the goals of the patient - not their parent and certainly not what I think matters.   

Throughout the weekend, there was an ongoing chat that allowed participants to interact with each other.  I particularly enjoyed the witty banter between the powerlifters and the weightlifters throughout the weekend.  As a person who likes to deadlift but who is fearful of destroying my living room if I try to snatch in my home gym, it was easy to see which side of those discussions I was on.  

Day 2: The Endurance Athlete

Presenter #3: was Ellie Somers (IG: @thesisuwolf), owner of Sisu Physical Therapy and Performance,  physical therapist, coach for running, strength, and businesses, and I'm proud to say, my friend, whose talk was "Communication with the Endurance Athlete." She previously worked at Seattle Children's Hospital. Ellie paired her own wit with the wisdom of Ted Lasso.  Ellie also emphasized the need to have a plan with a specific purpose that is meaningful to your clients and encouraged practitioners to highlight the strengths of their patients.  Too often in medicine we look at our patients and find all the things that are wrong with them.  That has to change!  Why can't we look at our patients and observe all the things that are great and empower them?  I've emphasized this approach in my patient care and loved the quote she shared "You're not in pain because you're weak, but getting stronger can help change your pain."  

Ellie also shared this article "The enduring impact of what clinicians say to people with low back pain" which I've read in the past and which is essential for young clinicians to read.  It's a 2013 study from New Zealand summarizing open-ended interview questions regarding healthcare interactions and beliefs from 12 patients with acute low back pain and 11 patients with chronic low back pain.  One theme was that patients had high trust in their clinicians and their beliefs were strongly influenced by what their medical providers said.  However, some patients did not find their clinicians to be competent or found the medical message to be a mismatch to their beliefs and rejected what the medical providers advised.  Almost subtle, a heartbreaking anecdote is a response from a study participant who shared that so many providers kept telling her back pain came from a weak core, she had an abortion because she thought she was too weak to carry and deliver a healthy baby. 

Presentation #4 was Chris Johnson, owner of Zeren Physical Therapy, triathlete, presenter, running coach, and physical therapist who performed a spoken word presentation which was a unique alternative to typical presentations.  Talking about running injuries, he dropped some true gems like "Tendons love tension; tendons take time (to rehab/heal)"  He talked about bone stress injuries with clinical pearl: Pain with unloading the leg should evoke a high index of suspicion for a bone stress injury (BSI) and when BSI is a potential diagnosis, no progression to running should occur until walking is pain-free. Another pearl was to stop worrying so much about footwear and foot strike position with running and consider other variables such as the sound of running instead.  I'll be very honest - I'm not an auditory learner, so I'm looking forward to re-reading the presentation when it gets sent out so I can further internalize the key messages and expand even further.  

Throughout the Summit, this same image appeared three times.  Isn't it nice that the presenters were so like-minded that this could happen?  The picture shows contributors to low back pain (and likely applicable to most pain) from this JOSPT paper from 2019. Too hard to read?  Doesn't that emphasize the point that pain is incredibly multi-factorial and the orange colored tissue-related factors are a relatively small contributor when you consider the big picture?  

In my opinion, the virtual format was excellent because no travel was needed, however that does lose some of the in-person benefits like networking events and dinners.  The organizers tried to combat that with a virtual Happy Hour on Day 2 where many clinicians hung out and chatted about whatever we wanted - which of course included the sports teams we support, where we're all at in the world, and lots of other interesting topics. 

Day 3: ACL Injury and Rehabilitation

Presenter #5 was Derek Miles a physical therapist with Barbell Medicine who is well known for his posts about pieces of meat (representing the human body) being poked, prodded, needled, scraped, taped, or treated with other common rehab approaches to demonstrate how some of these approaches are not doing what we think they are. (IG: @derek_barbellmedicine).  Derek kicked off day three's focus looking at the biopsychosocial approach for ACL injury.  He reiterated the need to have a plan with rehab, outlining that the first step after an injury is to get the patient back to being a human, then an athlete, and last should be consideration for their specific sport.  Walk, then run, then play basketball.  How do we achieve this? Post ACL injury or surgery, there's a long list of things that people can't do. Patients should know that, but clinicians can direct their attention and focus on all the things they CAN do.  Keep your athletes around their teams and with their teammates as much as possible.  Send them to practice with clear understanding of what they are able to participate in.  It's hard because there's a lot of discussion about what they shouldn't do, but make the injury an opportunity to learn the sport in a different way. 

Early ACL rehab may be boring, but it's the foundation to the later steps and often these athletes can do more than they think they can.  The ACL injury only directly impacts one limb... but there is another leg, two arms, a torso and a head that all need to continue functioning and training and should not be ignored.  If your clinic doesn't have sufficient equipment to load these athletes and get them stronger, sufficient space to get them moving, and have a way to test the athlete - you probably don't have enough to adequately rehab an ACL injury. The key takeaway: LOAD HEAVIER!  As Erik Meira so eloquently puts it, "It's the quad until it's not the quad."  Derek said he tells his athletes to do quad sets ALL THE TIME and then, when you hate them, do 5 more, and repeat again tomorrow.  No reps and sets.  Just constant.  I think I'll just writing 1,000,000 sets on my Medbridge HEP sheets from now on!

Presenter #6 was Laura Opstedal, owner of Build Physio in Montana who does lots of ACL Rehab and research and also previously worked at Seattle Children's Hospital. Laura reiterated Derek's points about quad strengthening and how important that is to athletic movements as well as the importance of testing athletes who have had an injured ACL prior to allowing them to return to activity.  For me, one particular quote stuck out from this presentation. "Look at your entire ACL rehab program as preventing a hip strategy and forcing a knee strategy.  Keep the trunk upright." I know I valued quad strength and testing before seeing this presentation, but I definitely was not doing a sufficient job avoiding the hip strategy.  In fact, I've been guilty of encouraging it sometimes, but Laura addressed the inferior patella pain that some patients feel with a knee strategy that I previously was avoiding, acknowledging that sometimes these athletes are going to have a little bit of pain and we need to know when that should matter and when it's ok to continue. ACL hip strategy study. It's only been two weeks and I've already changed this in the clinic. Also encouraged were achieving passive terminal knee extension within 10 days of surgery, having at least an 80% LSI before returning to run, don't ignore calf strengthening in our patients with knee injuries, and do more open chain knee extension. There were considerations for the slow stretch shortening cycle compared to the fast stretch shortening cycle and training them separately... yup, I never thought of my rehab in those terms before, though I do have some drills I like that focus on both, the new perspective is going to make a big difference for my patients. 

I definitely didn't do these presenters justice, but hopefully this "small" taste will encourage those of you who are rehab providers to start following some new clinicians and those of you who aren't in rehab who, for some reason, like to see what I have to say, hopefully learned about the complexity of pain and can gain some appreciation for the effort that any of your medical providers are putting in to maintain their licenses through continuous education and growth.   

One final note: "When a measure becomes a target, it ceases to be a good measure."  Using certain tests which are meant to be used to show progress and not to show culmination of progress is not the best approach.  I know I often feel like my return to sport tests are the end of my rehab.  This might be fine for some injuries like an ankle sprain where the athlete has been playing their sport without issue and I'm looking for a way to determine if symmetry has been restored.  But in the case of an ACL injury, the RTS testing often occurs to allow the athlete to start playing their sport.  This isn't good enough - and it's another chance to be less wrong tomorrow. 

Life in the Time of Quarantine

Hi Everyone -

Hope you're all hanging in there, enjoying being at home as much as you can, staying safe, washing your hands and faces.  Is your mental health ok?  Have you gotten any fresh air?  I know that might be hard for some people.  It has been over a month since my last blog post, but that was certainly not for lack of trying.  I've started to write several times in the past few weeks but the Coronavirus Pandemic has actually left me speechless. (Shocking, I know.)  I can't go to my usual coffee shop where I like to write and life has been turned upside-down, just like I'm sure it has been for anyone reading this.  I'm not a scientist and won't pretend to know anything about the virus itself.  I've never been more aware of how much I touch my own face - and even still I probably don't notice it more than half of the time. I'm not on the front lines fighting this, so don't let the masked image later in this post fool you.  I'm spending most of my time in isolation at home when I'm not in the clinic with occasional stops at the grocery store as needed.  Writing a blog post hasn't been on my priority list because I couldn't decide what to write about in the shadow of a global pandemic. As a writer friend recently told me, sometimes you just need to sit and write, let it flow, and see what happens.

Writing is an outlet for me.  I use it to help organize my thoughts and relieve stresses.  It offers an opportunity to be creative, use different areas of my brain, share ideas, highlight things I'm learning, and to show support for causes that matter to me.  At a time when I'm also not seeing my usual collection of mental health providers and also not going to the gym, the sudden and total removal of so many outlets has been a big deal. It helps to know that everyone else is in the same boat.  Nobody else is going to the gym.  We're all working out in our laundry rooms with whatever we have at home or going for walks in the neighborhood.  I've heard of people doing lots of different crafts, trying out meditation apps, yoga in the home, new types of exercise, and some people are buying pets in order to find novel coping methods. You're not alone...we're in this together!

So I'm writing today.  Without having any planned direction or goals.  I've seen a post going around on Facebook that people want to remember what was happening because this is going to be a historical event.  My parents remember when JFK was assassinated and my friends and I all remember where we were on 9-11.  This will be another memorable event for so many people... and nobody will forget where they were because we've all been on our couches for three weeks already!  So this is not my usual blog-writing approach. Welcome to my stream of consciousness.  My apologies for being scatterbrained.

At the beginning, I thought this was challenging because I felt trapped with nowhere to go.  My family is far away.  I was still seeing patients early on and didn't want to risk getting anyone sick. The first week I saw friends who had already started working from home, but then it seemed wrong for me to be around them.  Once I got into a rhythm, particularly with regular afternoon FaceTime gatherings, things started to improve.  The hardest moments have been worrying about my friends who work on the front lines, concerns about my parents and not being able to help them, and realizing that the Final Four was not going to occur.  This weekend should have been the Women's Basketball National Championship - often referred to as my favorite holiday.  Several of my friends here in Seattle have been connived into outings at random bars around the city to watch games with me.  I'm more than happy to treat my friends to some nachos if it means company to watch the Huskies. The NCAA College Basketball Season was so suddenly aborted after the best year of competition EVER. I don't think it quite hit me until all the replays from previous championships started popping up on social media and I realized how much sports can bring people together, how many years of my life I've spent watching basketball games, and how serious this pandemic really is.  You'd think being told to wear goggles, masks, and gloves to treat my few remaining patients would have been sufficient. If you've never worn them - those things are hot, sticky, and make your glasses fog up! 

So now that I've rambled on, I guess I should find some sort of purpose for taking your time.  All I can come up with is gratitude. On Wednesday, March 18th, I went into my clinic to call my patients and cancel their scheduled appointments. That was sad, but a few days later, I started to really miss what I do. I have fortunately had a few days in the office to treat high priority patients and each time I've seen a patient, I've felt life being restored to my body, air returning back to my lungs, energy surging, and the return of my dimply smile.  Endless gratitude reflecting on how my career has unfolded to this point where I have the world's best coworkers all collectively waiting to restore our previous routines.

I'm grateful for the small businesses in my local community who have been able to transition their usual operations to help support everyone at this time.  I've enjoyed some really good take-out meals in the past 18 days at home and highly recommend supporting your small local businesses that are trying to survive.  I'm grateful for all the people on the front lines - healthcare workers, front desk workers, environmental services cleaning crews, demand flow services, and leadership - in my office and throughout the country and the world who are taking care of so many sick people.  I'm grateful for books, the fact that I had too many out from the library when this all started that I'm slowly working my way through, and also audiobook downloads available from the library, and Netflix and Amazon having rentals to watch movies.

I'm grateful for all the different electronic user interfaces that have made it possible for me to have face-to-face conversations with so many people.  Between FaceTime, Facebook Messenger, Skype, WebEx, Zoom, Google Hangouts, and HouseParty - it really isn't hard to connect, but those virtual gatherings don't quite feel the same. There were a few days last week where I bounced from call to call catching up with old friends, seeing how family members are doing, and trying to find that missing sense of connection.  Today my extended family gathered on Zoom in preparation for Passover to begin on Wednesday.  Check that out! People in 20 different homes in at least 10 different states ranging between Washington, Connecticut, Florida, Ohio, Oklahoma, California, and Washington, D.C.

I'm worried for my friends who are working to save lives.  They have families and kids of their own and are at extremely high risk. I wish I could do more to help them, to help sick people, I guess just to help anybody. The most any of us can really do right now is to stay at home and prevent further spread of the virus. I'm very hopeful that when this all ends, there will be improvements made to how we operate as a country and as a healthcare system.  Let's hope this wraps up in time for everyone to enjoy summer.  Let's hope this doesn't destroy families financially, or in any other ways.  Let's hope we can resume travel soon.  Let's hope everyone stays healthy and safe.  And let's hope we can have a massive celebration together on the other side. Let me know if there's anything I can do to help you out.  We're all in this together.

What Do Physical Therapists Do? Installment #7: We Collaborate

Today is my three-year workiversary at Seattle Children's Hospital.  To celebrate, this blog post will be the newest edition on my "What Do Physical Therapists Do?" series where I'll share a recent experience collaborating with a non-PT colleague. I've previously written six other posts regarding things that PTs do: those can be found here. I think there are many careers or jobs which encourage collaboration, but the variety of people I work with is so vast, that its worthy to give this some consideration.

One of my favorite parts of working at the Seattle Children's North Clinic is the way the rehab work space is organized.  I share my work area (documentation space and the gym) with my colleague sports physical therapists as well as rehab physical therapists, occupational therapists, speech language pathologists, and rehab aides. My desk faces the rehab PTs desks.  They treat an entirely different patient population than I do.  I'm so grateful that there are PTs who do what they do, because despite what my license says, that work is not what I was meant for. They're amazing clinicians.  It's no secret in my office that I struggle to work with shy kids.  I fill awkward silences with awkward conversations.  The rehab therapists can spend an hour working with children who do not communicate at all.  It's amazing. They make rehab into games, balancing on one foot while playing connect for or pretending to be dinosaurs or avoiding lava while they're walking across balance beams or completing obstacle courses. They use the same equipment I do and I absolutely steal their ideas to use with my patients.  My fellow Sports PTs also come up with creative approaches towards rehab.  We don't have a sled in the clinic which is a tool you can use to load up some weights for patients to push or pull to build up some leg and core strength and endurance.  One of my coworkers has become the sled of the office - kids drag him while he holds onto a jump rope with his feet on sliders.  I'm too scared to attempt that one, but for sure I steal from my colleague Sports PTs in numerous ways. Call it collaboration or call it learning or call it stealing ... whatever word you prefer, being around this group of providers helps us all learn.

An OT, PT, and SLP collaborating at the North Clinic

I recently worked with a patient who had pain related to prior surgeries on their face and mouth. I have previously worked with patients with jaw pain and cervicogenic headaches and concussions, so this body region isn't too unfamiliar to me, however her condition was unique and I wanted to give tongue exercises as part of her home exercise program. I needed help, so I went straight to the speech pathologist who sits three desks away to get recommendations for my treatment plan.  She was super helpful in considering my thought process for a patient who didn't fit into her usual case load either.  There were no language issues involved. But her knowledge of the way the face and mouth work combined with my understanding of strengthening principles and chronic pain were a perfect combination to help this patient.

Beyond my coworkers, I also work with a huge variety of healthcare providers and non-medical personnel.  This includes community pediatricians, orthopedic physicians and surgeons, athletic trainers, rheumatologists, mental health providers, podiatrists, biofeedback technicians, anesthesiologists, neurologists, interpreters, adolescent medicine, social workers, supply chain workers, family service coordinators, the billing department, nurses, medical assistants, our information technology representatives (without which I'm sure I would have somehow made a computer blow up by now) and occasionally oncologists, endocrinologists, and cardiologists. Of course let's not forget the most important people we collaborate with: the patients and their families!  I have previously written about how important I think therapeutic alliance is several times such as here, but this is just another excuse to mention how much I love connecting with patients and people in general. The rehab PTs work with a different set of providers than I do, adding in durable medical equipment contractors, prosthetists, school and community resources, and certainly many more that I'm not even aware of.  It's really cool to have this large of a network to interact with, particularly because the human body is so complex.

And so, in celebration of my workiversary, I'm really excited to share another edition of "What Do Physical Therapists Do?"  Without question, this field encourages collaboration.  My experiences are certainly unique, but this is just one of many ways to say that communication skills are essential in healthcare. It is also an extra opportunity for me to give thanks for all the people I work with, including my patients and their families.  For sure I am a better physical therapist because of all of you.

Book Alert: Graded Motor Imagery Handbook

How is it already mid-February?  I swear each year flies by faster and faster... and yes, I realize that's a cliche thing to say.  I did some really fun volunteering earlier this month that took up my usual blogging hours, so I'm long overdue for a post today.  I'll be writing about those experiences soon, but today I've got a Book Alert on the Graded Motor Imagery Handbook, by Lorimer Moseley, David Butler, and their crew with the NOI Group.   The NOI Group is the Neuro Orthopedic Institute of Australasia that teaches a variety of topics related to neuroscience and pain.  I've previously written about their books Explain Pain and Explain Pain Supercharged as well as my experience meeting Lorimer Moseley here. You might call me a NOI Group Superfan at this point since I think I've read all their books, but not their research articles because there are hundreds of those.  Working on it.  This topic was fueled by my work with the Seattle Children's Hospital Pain Management Team, and every time I read one thing, I identify tons more to learn about.  Definitely falling down the chronic pain rabbit hole over here.

The Graded Motor Imagery (GMI) Handbook was on my list of six books I wanted to read in 2020 which I'm tracking on the right side of the blog for the year.  One down, five more to go!  Now that I've read it, I've already started incorporating the concepts into practice, and if you're a physical therapist, I highly recommend you read this, particularly if you treat patients experiencing chronic pain or CRPS, but also this probably should be considered with more of our patients. This topic, as are all the topics that come from the NOI Group, is complicated, so I'm trying to share my understanding of what I read.

I've chosen one example to use to demonstrate the concepts of GMI throughout this post.  GMI can be applied to injuries anywhere in the body, though.  I've used it more in extremities than in the spine, but I also don't treat many patients with chronic neck or back pain in the clinic.  Let's say you sprained your left ankle playing soccer yesterday.  It hurts.  You've just injured it!  It is reasonable to have pain right now and the amount of pain seems appropriate based on the mechanism you experienced. Tissues may have some damage - maybe your anterior talofibular ligament has a few fibers that were damaged.  This is the most commonly injured ligament in an ankle sprain and you've probably already hurt it before if you're playing soccer.  Maybe you see some bruising, swelling, and are having a little difficulty walking.  The XRAY says you didn't break anything.  The doctor at urgent care puts you in a boot and tells you that you can do as much activity as you can tolerate and that you can wean out of the boot in a week or two. 

In this acute phase of a recent injury, your brain is processing many inputs from your injured ankle and it does so in the "typical" way.  The brain processes the sensory inputs from the ground and the boot and produces your pain experience.  Maybe you don't have much pain because the injury has occurred and ended, no additional threat is perceived, and you know that you've had this experience before and that things will recover quickly.  You think you'll be ready for the soccer tournament next month without any issues.  This is when you think, "phew, it's not broken and it's not really even hurting that much.  I'll just wear this boot and be back to normal soon."  You probably won't even see a physical therapist, though I've previously written here why you should, even if it's just a minor ankle sprain. 

But what happens if, for a variety of possible reason(s), the pain doesn't go away, or maybe even worsens. Your simple ankle sprain from playing soccer persists longer than you think it should.  You find yourself unable to wean out of the boot after several weeks of wearing it and you've gone back to the doctor who does an MRI that says there's some mild damage but your pain level has remained higher than it should be.  You've finally gone to your physical therapist and they have been able to get you walking a bit more, but you still can't really tolerate activities and pain is worse than what you expect.  Maybe swelling persists and you're still having trouble walking a few weeks later. Sometimes you could even experience a cold, sweaty, purple foot with weird growth of your leg hair or toenails on that side.  You've stopped playing soccer and are spending less time out with your friends because that's where you would typically see them.  Maybe you've declined invitations to hike and are even losing sleep sometimes because your ankle hurts.  Your job is being affected because your work requires you to stand for extended periods of time and you can't tolerate that because your ankle still hurts.  All of this from a little ankle sprain that isn't healing the usual way.

The research in the GMI Handbook (of which there is A LOT) explains that people who experience chronic periods of pain sometimes lose their ability to differentiate between their right side and their left side.  The brain is affected by your ankle injury.  In some patients, you might even start feeling pain on the other ankle.  If you're thinking what I was thinking when I first read about this, you might be thinking "No way!?!?!?! How?!?!"  That's how I felt, at least.  

Now that I've started using GMI assessments and treatment tools in the clinic, I can actually see that patients have difficulty doing this. I wouldn't have believed it if I hadn't seen it for my own eyes.  Ive worked with patients, particularly with foot/ankle injuries, who haven't put their foot on the ground in months.  MONTHS!  They're spending time on crutches or even worse - in wheelchairs.  They exhibit fear towards walking, standing, or even having their feet touched.  The brain is processing input signals - maybe even caused by being in a boot - for far too long and starts to understand the input signals differently.  Not only does your brain start to confuse things, but it also starts to react to stimuli in new ways.  Things that wouldn't typically hurt most people, like the feeling of your sock on your ankle, now hurt. This is called allodynia: a central pain sensitization in which neurons exhibit increased response to normally non-painful stimuli.  Basically - you experience pain to a stimulus which typically would not be painful.  I see allodynia frequently in the clinic and have actually experienced it for myself.  About eight years ago, I badly cut my finger on one of those apple corer things while helping my sister cook Rosh Hashanah dinner for our family.  Sometimes even now if I touch that old cut, I might feel a sharp pain and pull my hand away, but usually I don't even notice it.  Patients who have had chronic pain sometimes cannot tolerate me touching their foot with my hands or even a towel because it feels too painful. They pull away or shout or cry or sometimes even kick me (unintentionally, I'm sure), and they recognize that their response to what I'm doing doesn't make sense.

Graded Motor Imagery is a tool to try to restore the brain's proper understanding of left versus right while exercising the brain.  The book outlines a series of steps starting with understanding left versus right, followed by imagined movements where the patient concentrates on their injured ankle while mentally picturing themself doing activities like walking, followed by the use of mirror therapy to almost trick the brain into thinking that their injured limb is moving without pain while you're moving your non-injured limb while looking into a mirror.  

From the Recognise App

When I see a patient experiencing chronic pain of their ankle, I'm using an app created by the NOI Group called "Recognise Foot" (yes, spelled that way, because they're Australian and they don't like the letter Z).  The app shows you pictures of a foot and you have to identify if it is a left or a right one.  (They have apps for several different body parts).  You can change the settings to start with fairly simple images like this one --> with a black background in typical positions to more complex images with varied backgrounds that are covered in paint or wearing a cast or flipped upside-down and it's basically like playing a game to see how fast you can identify the side of the body and how accurate you are.  I've tested out the app for the hand (Recognise) and the app for the foot (Recognise Foot), each of which are $5.99 at the App Store.

A normal result would be at least 90% accuracy and symmetry between sides as well as response time of less than .2 seconds.  The app will tell you your scores and you can use it to assess the patient's ability to discriminate between left and right as well as treat them using the app. I've been adding this as a home exercise program component to patients who have been experiencing chronic pain and having them "play the game" several times per day in addition to doing some activities to try to get them moving towards less pain. 

A word of caution: the GMI Handbook does say that some people will experience pain just from using the app. This is not something I have experienced yet, but if it does occur, there are ways to change the settings on the app so the patient has more time to respond or less images. Also you can actually regress from this to watching other people move, focusing on the other person's body.  For example if your ankle pain was increased just by using the app, you could go to the mall and watch people walking and focus on their ankle instead.  There's science to support this regression and the book talks discovering this using monkeys who would watch people eat and some of their own brain cells that would be activated if they were eating would "light up" as if they were doing the activity themself. It's a less intense way for your brain to process information, watching someone else do an activity, because of the ways the sensory and motor cortexes of the brain are uniquely used with watching versus participating in activity.

Ultimately, GMI is a science that is still developing.  There is research to support some of the claims, but not all of them and the NOI group points out where there are holes in the evidence.  There is evidence to support using this treatment in specific patients, such as those with CRPS, and less evidence for others.  Some of my colleagues are using this treatment more frequently and with patients in more acute pain states.  Some colleagues don't use it because they don't know anything about it - like myself only a few months ago. The app is actually pretty fun and if you don't have pain doing it, who wouldn't benefit from some brain training?  I'm tempted to see if the basketball players I work with have any change in their reaction time by using this sort of brain training to try to use if for performance enhancement, but again, I have no evidence to support that thought and can't usually use them as guinea pigs.  I'm curious to know who else is using GMI in their clinical practice, how often, for what conditions, and what others have found with using it.  And I highly recommend that PTs read this book to learn about where we are on this type of patient care right now and to see if it might help some of your patients.  

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. 

I'm a Book Nerd

I really love to read.  I don't think anyone who knows me would be surprised to hear this, and I've written a bit about this in the past.  I've written a few book reviews (you can search the blog for those easily if it interests you), and I wrote about my anti-library here.  I constantly have a book in my bag, an audio book in the car, a creased journal that I'm mid-way through reading usually on the back seat of the car, on the side table in the living room, and in my laptop bag.  There are things to read everywhere!  I even occasionally have an audio book on my phone to listen to, now that I figured out how easy it is to connect an app on my phone to my library account.  The ways to access knowledge continue to skyrocket and I feel like I just keep devouring more and more, but each thing I read just shows me multiple new sources I can add to my list.  I remember fondly the days when I only read fiction, many years ago, and I'm embracing the transition that I've gone through to make it so I'm about 60% non-fiction and 40% fiction reader now.  I love getting lost in a tale of unique characters or far away places and won't really ever stop reading fiction entirely, but the non-fiction and the science are so fascinating, too!  I read about a huge variety of topics  But I also like reading things that help me grow as a physical therapist and as a person.

Last week I was working with a teenage patient in the clinic who I have had the opportunity to work with over more than two years following multiple surgeries.  She was telling me about her most recent Netflix binge and asked what I was watching.  When I told her that I didn't have a TV or a Netflix account, her jaw hit the floor.  It's not like I don't waste plenty of time on Facebook or goofing off on my phone or watching movies or occasional shows.  For certain, I do. Some days I want to go back to my old flip phone so I could have less access to all the distractions my Smartphone provides.  When I told her I read books, she called me a nerd.  And I wear that title with pride.

Until now, I've kept a running list of books I want to read on Goodreads and as I get close to finishing one, I just pick the next one. Sometimes a friend or coworker recommends a book and I pick it instead of what's been on my list for a while. I'm a regular at the local library and when they don't have something I'm interested in getting, I can use the Seattle Children's Hospital Inter-Library Loan System to get my more sciency books.  I've had a list of the "Top Five To Read Next" books on my list for years... but some of those books have never moved off the list because I read others first.  I've never really wanted to commit to making a plan of topics or books to read and sticking to it because I liked the flexibility, because I don't want reading to feel like an obligation, and because I have been reading so much, that I didn't think it really mattered.  But I'm not reading some of the things I really want to get to, so I'm going to try a plan this time.

For 2020, I'm picking a few work-related topics ahead of time with the goal of reading at least one book for each of those topics.  The books have all been on my list, some for years.  They've been recommended by people I respect.  Some match my personal beliefs and some are a bit more contrary. They seem interesting from their descriptions.  They're bound to help me grow as a physical therapist, and also likely as a human being.  Though I've written them as if they are in some sort of order, that may change.

Graded Motor Imagery Handbook + Mocha = JOY

The first book is "The Graded Motor Imagery Handbook" by Lorimer Moseley, David Butler, Timothy Beames, and Thomas Giles. You may have read my previous post about when I met Lorimer Moseley as his team studies pain extensively and he's written several books, which I've also written about here and here.  I don't actually know what topic this specifically falls under.  Maybe pain, maybe physical therapy treatment, maybe neuroscience.  Either way, this book has been on my list for a long time.  I just started it and can already tell it's going to be a journey. I expect this experience will be like climbing the mountain that "Explain Pain Supercharged" was.  In the event I decide to dig even deeper into this topic, I'll read some of the resources or books recommended within it, such as "Phantoms in the Brain" by V.S. Ramachandran, or one of his other books.  This is how I start to fall down the rabbit hole.  Speaking of which, I hope to read "The Adventures of Alice in Wonderland" in 2020, also.

The second topic will be pain.  Shocker, right?  The pain saga continues.  I've been wanting to read "Gift of Injury" by Stuart McGill which is about recovery from lower back injury and if I'm able to get access to it, I'll also read his book "Back Mechanic" to make a more focused reading cluster about low back pain.  And I also have "The Gift of Pain" by Dr. Paul Brand and Phillip Yancey on my list.

The final subject will bring me back to the basics: a look at Anatomy by reading "Anatomy Trains" by Thomas Myers.  Hopefully a refresher on the basics of anatomy with new learning about the fascial system.  I think this book is going to go against some of my biases, but I'm not sure yet. The list of these six books is now at the right side of the blog and I'll be checking them off as I complete them throughout the year.

In addition to these books, I recently launched the Seattle Children's Hospital Sports Physical Therapy Journal Club.  After recommendations from many of the physical therapists I met at the AASPT Fellowship I wrote about here, a few editions have already gone out looking at the "Linking Evidence to Practice" series in JOSPT written by Dr. Stephen J. Kemper that teach readers how to critically evaluate scientific literature.  I won't lie... those papers were a bit dry, but they're important. Too often we read a journal article and take every word of it like it's gospel when in reality there are other papers that share opposing views or the methodology is not really sound.  I'm guilty of this myself, and hope to learn more about the biases I fail to recognize in my own treatment methods. I'm really looking forward to getting into some more interesting papers that have been recommended and I hope to share some of those here on the blog, also.  Specific topics I'm looking forward to reading about in the scientific literature include: the basics of tendon structure and healing, more about evaluation and treatment for concussions, therapeutic alliance, the mechanisms of manual therapy (this will be the next paper, thanks for the recommendation Jarod Hall), and looking at different conditions we treat in the clinic.  Anybody who wants to join in on our journal club emails, just say the word and I'm happy to share.

I guess I've been blogging more and more about PT-related topics, though once the WNBA season starts back up, I'll still write about basketball... or maybe about things that interest people that are not physical therapists.  Until then, I'm loving all this PT learning and personal growth and want to know what others are reading to help grow their clinical practice.  Or just books you liked.  There's always room for more on my list.

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.