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. 

Breaking Up With My FitBit

My Only Half Marathon

Towards the end of 2017, a friend asked me if I would be willing to commit to running 1000 miles in 2018 as a motivator for her training for some half marathons.  She's a good friend... like really good... like one of my favorite people on the planet... but that was an easy question. Heck no!

I'm not a runner.  In fact I think I hate running.  I can run. As in, if a bear was chasing me or I happen to be facing oncoming traffic, I could get out of the way at a faster pace than my usual walk.  I have run road races in the past - including running our first half marathon together.  There's a chance I'll run a 5K again... those are fun.  But after we ran the half marathon, she just continued running them.  She's probably past 30 half marathons by now.  I didn't run another... and I can't imagine I would.

There are so many ways to exercise that it's not a big deal that running isn't on my list of choices.  Occasionally at the gym I choose the treadmill and get in an interval training session instead of a bike or elliptical, but in general I choose lifting weights and a class whenever possible.  I think the only time I really choose to run is when the weather is nice and I can be outside or I'm exploring a new place.

So I agreed to completing 1000 miles on foot with the goal being to walk that many miles in a year... and she would run them.  I got a FitBit that I wore pretty much every day for 2018 to track my progress and it was really fun.  The FitBit app lets you cheer others on and does some fun things when you meet your daily goals.  I completed 1000 miles towards the end of September and felt like wearing the FitBit tracker definitely motivated me to go a little bit further.  If I was wrapping up my day and it said anything over 9,000 steps, I almost always found a way to wander the house to hit that 10,000 step milestone.  I jogged in place reading a book that was resting on top of the laundry machine or paced the hallway back and forth listening to a Podcast just to finish that last 1,000.

There were certainly a few days where I did next to nothing... but overwhelmingly it increased my motivation to move.  When I looked back, there were only 5 days in 2018 where I walked less than 1 mile.   There were also a few days when I walked more than 10 miles in a day hiking.  So those are balanced out, right?  I started walking on my lunch hour a few times per week and when my job relocated to a much larger building, my step count increased just by having the bathroom and lunch room considerably farther away.  I really liked seeing how the tracker affected me and how the job change affected my movement.

But now it's 2019, and the FitBit is no longer on my wrist.  There's two reasons for this change.

First - I've decided it's time for my body to tell me when it wants to move... not a machine.  Some days after work I'm just downright tired and don't want to go to the gym.  I'm tired of making myself feel guilty for taking a day - or even a few days in a row - off from exercising.  I think I may have been torturing myself a little last year to make myself move more than felt good for me.  And... when you're on the stair climber or the elliptical at the gym, if you don't move your arms enough, the Fitbit didn't register it so it's like you didn't work out, and then a stupid machine was making me feel bad.  I'm not into that.  Funny enough, if I type aggressively enough during the work day, the FitBit also recorded key strokes as movement...and that's just ridiculous.  Sometimes I just type with purpose!

"A Beautiful Mind"

Second - I tracked everything I did last year.  Every mile I walked.  The food I was eating.  Workout days, stairs trained, progress towards personal goals, even the books I read. There's a beautiful thing about tracking in that it shows a lot of accomplishment and completion of tasks.  There's also the opposite effect - I was intimately aware of all my failures.  I set some goals that were not reasonable and every time I noticed how far I was from achieving them, I felt bad.  My 2018 planner looks like John Nash's office in "A Beautiful Mind."  Circles and lines and random numbers with symbols for workouts everywhere.  The tracking needs to go.

So... if I go for a long hike with my friends this year, I'll probably grab the FitBit to see what the daily mileage looked like.  If I can find it and was prepared enough to charge it. But it'll be because I'm choosing to move and curious to know how much.  If I need a day on the couch... which doesn't happen that often... I'm going to embrace it instead of feeling bad about it.  And maybe the sun will come back out in Seattle, and I'll chose to go for a run.  Or go kayaking... because I love that far more.

As always... if you have a FitBit or other kind of tracker... you should use it how you like.  You do you.  I'll do me.  

Real Athletes Poop Their Pants - And love the Jonas Brothers?

It was the summer of 2007 and I was working as the Travel Coordinator and Equipment Manager for the Connecticut Sun WNBA Team.  I had just graduated from UConn so maybe all the time I spent studying meant that I was a little behind on my pop culture.  One game the ball kids were going crazy with excitement about the half time show performers: The Jonas Brothers.  I had never heard of these guys, but they were so excited so I managed to snap a photo of the ball kids and the Jonas Brothers together.  In 2008, the Jonas Brothers were nominated for the Best New Artist Award at the Grammy's... so they must have been pretty good.

#TBT - the Jonas Brothers (Kevin, Joe, and Nick) and the Connecticut Sun Ball Kids (Carly, Maggie, and Clare)

Interesting fact about Nick Jonas: he was diagnosed as a type I diabetic at age 13 in 2005 - not long before that photo was taken.  The Jonas brothers as a band were pretty big from 2007-2011.  In 2015, Nick Jonas co-founded the group "Beyond Type I" whose mission is to educate, advocate, and provide resources to those who face diabetes.   This past week, Beyond Type I featured one of my closest friends on their website telling a story about her experience with Type I Diabetes as a long distance runner.  Her post has been re-posted in its entirety below, but before we get to her humor - here are five things you should know about Type I Diabetes.

1) The difference between Type I and Type II Diabetes:
Type I Diabetics are unable to make sufficient insulin in their pancreas to regulate their blood sugar.  The function of insulin in the body is to bring sugar into cells so it can be used for energy.  Without insulin, sugar remains in the blood which can harm organs and even be fatal.  Type I Diabetes is not curable, but through constant attention to diet and supplemental insulin, people can live full lives with the condition.  This differs from Type II Diabetes in which a person has built up resistance to insulin at their cells over time but whose pancreas still makes insulin.  Type II can be reversed through dietary changes and exercise.

2) Signs/symptoms of Diabetes:
With both Type I and Type II diabetes, it is common to experience increased urination, increased thirst,  and dry mouth.  Type I diabetics may also experience fatigue, abdominal cramping, nausea, vomiting, and a breath smelling like acetone which are less commonly seen with Type II diabetics. 

3) Insulin supplementation:
Type I Diabetics use supplemental insulin to regulate their blood sugars because they are unable to do so naturally or by diet and exercise.  They have to constantly track their sugar levels and consider the impact of anything they eat and the effect it will have on their body. Because they supplement with insulin, they can also experience hypoglycemia (too low blood sugar.)  Signs/symptoms of too low blood sugar include sweating, shakiness, light headedness, confusion, and fainting.  Because of the severe impact of low blood sugar, if you happen to come across someone with an ID bracelet identifying that they are diabetic, it is potentially lifesaving to give them sugar and call 911. 

4) Global Issue
While 90% of diabetics are Type II, the trend has been increasing for Type I by about 2-5% per year.  The frequency is not evenly distributed around the world.  For Type I Diabetes, Finland has a high frequency, the US has a moderate frequency, and China has a low frequency.  Interestingly, the above linked paper also notes that none of the regions had more females than males with Type I Diabetes but I only know four people with Type I Diabetes and they're all women. It is important to recognize that there are essential differences between the two conditions and that because Type II is so much more common, you need to be aware of which type you're reading about because the information usually does not apply to both types.  Diagnosis, treatment, and medications differ between Type I and Type II. 

5) Genetic Disposition
Multiple genes have been identified to relate to Type I Diabetes, but 40-50% of family linked cases relate to chromosome #6 and variations in Human Leukocyte Antigen which is a regulator of the immune system.  In the USA, 1 in 20 Type I Diabetics have a family member with the condition compared to 1 in 300 from the general population.  Identical twins are seen to have >60% and fraternal twins 6-10% occurrence of Type I Diabetes.  Children diagnosed before age 5 are suspected to have a higher genetic predisposition in their family than those diagnosed later in life.

Enough of the serious business and back to the reason for this post.  The following article first appeared on the "Beyond Type I" site here on April 11, 2018 and was written by my friend Cat Carter (reproduced with her permission).  She has run 29 Half Marathons - at least half of those since she was diagnosed with Type I Diabetes.  I like to claim that her running habit is my fault, as her first half marathon was in Providence, RI, with me.  If she ever commits to running one in Seattle, I'll get back to training to do another one - but until that time, I stair climb and I don't run.  After Providence, she kept running them and I sat in a chair in the corner of Koon's Hall at UConn for the next 3 years. There has been extensive debate about how and when we met, but we've been friends for at least 15 years and I lived with her for all of PT School - so if she can suffer through the terrible person I was when hungry and sleep deprived, she's gotta be worth getting to know.  Enjoy her post!

With Cat Carter before the Providence, RI Half Marathon

I run half marathons for many reasons. a) I enjoy the physical and mental challenges each race offers. b) Runners are some of the friendliest folks around, so although I prefer to train alone, I have met some of the kindest and coolest people at races and in my running clubs. c) My internal motivation is super in the toilet, so it’s a safe bet that I won’t exercise without a race on my calendar. d) The world is full of blissfully ignorant fools. Harsh and unkind words, I know. But seriously, how often do you hear ridiculous diabetes jokes? How many instances can you think of when the media, a politician, or another individual or group with influence and power spread blatantly wrong information about the disease? I run to prove them all wrong and spread our Truth.

And e) I like medals. I like how they look hanging on my wall. I like how they sound when they clink together. And I love the memories and feelings of accomplishment each one of them evokes. I’m not at all above doing a race for the bling. I did a race in Amish Country one time because its medal was a horseshoe. A horseshoe. It was awesome. And my amazing wife was inseminated without me there because I was doing a race that had a shark finisher medal. (Yes, you read that right. Who knew it was going to take on the first try? I mean, really, what are the odds? Mama loves you, Liam, and I promise I won’t miss any other critical moments of your life.) So when I found a race for which the medal was a grilled cheese sandwich (a local race no less – you go, Connecticut!) you bet your ass I was all in.

Unfortunately, that particular June day in 2016 turned out to be rather rainy. Now normally I don’t hate running in the rain. It’s not the worst thing ever. Sure, putting all of my (diabetes tracking/treating) devices in waterproof bags is less than ideal and a royal pain in the ass, but it’s manageable. While we’re here, how many of you hate that word? “Manageable.” Ugh, gross. It’s almost as bad as “moist.” If I hear one more person say, “Hey, don’t worry, diabetes is manageable,” I’m going to come unglued. I think the world needs a quick tutorial on the meaning of “manageable.”

Aaaaaaaaaaaaanyway. I’m going to reel myself back in. Where were we? Yes, the grilled cheese race. Okay, so there I was plugging along mile after mile when I felt something … below. Like, below, below. In the bottom of my pants below. So I did what any human being who thinks they’ve just pooped their pants would do: I panicked internally for roughly three minutes. Which I know doesn’t sounds like a long time, but do me a solid – pun intended – and take a pause for three minutes. While taking that pause, imagine you’ve just pooped your pants, you’re in a very public place, and you have absolutely no idea where the nearest restroom is. Now, can we agree that three minutes is on the same level as an eternity?

Here was the major problem – not only was the medal a grilled cheese sandwich, but all finishers also got a real grilled cheese sandwich with chocolate milk. I was wicked hungry, and I really wanted that sandwich, but you cannot just roll into the food line at the end of a race with poopy pants. You will make exactly zero friends doing that. So I summoned the courage to nonchalantly check the damage, and much to my relief it wasn’t poop … but my Omnipod. That slippery little sh*t.  My pump! I never thought I’d be excited to learn my pump fell off, but at that moment in time I was damned near ecstatic. It was the first race I’d done in the rain since diabetes, and I didn’t even think to reinforce my pod. Stuck to my upper buttocks, it must have lost its adhesion in the *moist* conditions and slid down. Thankfully I had a pen in the car I could use post-race for my coveted sandwich, now only a short 2 miles away – crisis averted.

In closing, real athletes poop their pants. I’ve read about it on the Internet, so it must be true. See here, here, and here. What did I tell you? It’s totally, 100% a thing. So if I thought I pooped my pants and didn’t slow down (or cry!) … I must be a real athlete, too. Go. Me. And if you’ve ever pooped (or peed) your pants while getting your diabadass workout on, then go, you, too!

Who needs drugs when there's hot yoga?!

Photo Credit: Geralt

I once wanted to be a runner. Not an elite runner, just someone who liked going for a long, casual, weekly run as part of a healthy routine.  This seemed like a good plan for my future, so I read several books about becoming a runner - all of which said consistency was key.  So I ran.

In 2011, I trained for (and completed!) a half marathon.  Starting at three miles, I followed a charted training program with progressively longer runs every week for at least 12 consecutive weeks. Once I got lost while running an 8-mile route, ultimately going 13, and at some point I ran out of water and cried to a gas station attendant who gave me a cup and showed me a map to get home.  My sense of direction is THE WORST.  It was a few weeks before the race and the only positive of that experience was learning I could crawl 13 miles to complete the race if I had to, but I would cross that finish line.

And then race day came. Several of my best friends were also running that weekend in Providence, RI.  Four of us had booked a hotel room near the finish line.  The race started without issue, mostly flat with a little bit of a hill at the 3rd mile.  Mid-way through the race, a lady thanked me because I had been belting "Party in the USA" by Miley Cirus at the top of my lungs and she had forgotten her headphones. Poor lady.  I remember hitting the 10 mile marker and thinking: only 5K left to go! I've run several 5K's.  No big deal! And then my body started to say "Nope!  No More."  It was horrible and I wanted to die right there on the side of the road. I decided then that running wasn't for me.

I think I recall the day so clearly because upon waking the next morning, incapable of moving my legs despite the ice bath I had endured the night before, I remember watching the news to see President Obama announcing that Osama Bin Laden was dead. Last night, I finally learned why running is the worst.  In all the training runs, the 5K races, the half marathon race itself, and in every road race or stair climb I've done since then, I’ve never experienced what is commonly called “The Runner's High”. Sure, I feel good after a workout, but something was missing. 

"The Runner's High," according to this 2008 publication from the journal Cerebral Cortex, is defined as "a euphoric state resulting from long-distance running." The paper goes into detail about how they were studying opioid receptors in the frontal and limbic regions of the brain (the brain parts responsible for personality, behavior, mood, fear, and pleasure).  The measurements were done when the runners completed about a half marathon distance, so likely I just don't run long enough distances to get there.  But I don't want to run those kinds of distances to feel so good.

Last night I achieved the fabled runners high in the most unlikely of places.  I went to a power vinyasa class at Fusion Hot Yoga.  Sixty minutes of constant motion with a room full of strangers (and one friend) sweating profusely. They were celebrating the company’s birthday with a day of free classes and the participants were packed in - sardine can style.

The instructor, Brian Pittman, started class off with some supine bicycles. I have patients do 20 of them in the clinic all the time - nice! I know what I'm doing.  When we hit 50 I started to lower my legs, and then he said half way! Ha! I was sure I was done for and basically ended up in a static dead bug pose thinking “what have I gotten myself into?!” I’m not sure how hot the room was but if I had to guess it was about 85F with 1,000,000% humidity. It felt like I was swimming in a bowl of soup. I LOVE the heat.

I was thrilled to remember the names of many of the common poses and a frequent sequence of a low plank into an up-dog followed by a downward-facing-dog. I only felt like I might pass out twice and gave myself a few extra breaths in child's pose and some water to recover.  Afterwards, the adrenaline started.  I turned off the audio book in the car for the ride home so I could sing along to the radio.  I stopped for gas and was jumping up and down full of energy, and still sweating.  I slept the greatest sleep ever.  And then I woke up today and felt the high energy continue for most of the day.  Maybe it's all in my head... but I'm happier believing that I had a whole day of runner's high from an hour of yoga.  All day long I've wondered - how is there an opioid epidemic in the world - yoga has to be cheaper than heroin and this high has to feel infinitely better.  It was hard work to get there, but it didn't require me running 13 miles.

So this is my new solution to the opioid epidemic: for treatment of back pain or for detoxing off a heroin addition - see a physical therapist and go to hot yoga.  I already bought my Groupon for more classes, so you can come join me to sweat it out!

Running Mechanics Assessment for Physical Therapists

Two days ago - I wrote that Physical Therapists should be looking at mechanics - triggered by a patient coming in needing their running mechanics assessed after a physical therapist said they didn't do this work.  I had every intention of writing my own blog post on some of the key things to look for to assess running - but then Mike Reinold posted a write up  this morning based on Chris Johnson's running training - and they're experts.  So rather than re-invent the wheel - Here's Mike's post from today entitled: "A Simple Approach to Running Mechanics for Clinicians." (Seriously this could not have been more timely!)

Quick Summary:  Chris and Mike are recommending you look at the Four S's: Sound, Strike, Step Rate, and Speed. While this is not exactly the same method that I assess running form - I'm thrilled to see how they do it, and I can't wait to update some of the techniques I've been using.  I'm big on listening to the sound that my patients make - with running, walking, jump-landing, and plyometric activities - so this was not new to me.  I've never seen an app to use for cadence - only learned about using a metronome which I have done on a few occasions.

Ultimately - check Mike's post to learn some simple things you can look at in a runner experiencing pain to try to fix their form.  If you can't fix it so they're pain-free, find someone who's an expert such as Mike and his crew in Boston or Chris who is here in Seattle.

Happy Holidays!

What Do Physical Therapists Do? Installment #1: We Look at Mechanics

Recent scenario evaluating a high school-aged patient: let's call him Bobby and pretend that he's referred with a diagnosis of shin splints. (We can get into "Shin Splints" not being an actual medical diagnosis on a different blog post).  The conversation went something like this:

Abby: Hey, what brings you in today?

Bobby: I'm here for biomechanics testing.  I want to get back to running ASAP.

Abby: That's awesome that you like to run. 

Bobby: I run track and cross country but my leg hurt a whole lot at the end of the last season.  I saw the doctor and he shut me down from running while I did 2 months of physical therapy elsewhere.  When I went back to the doctor, he said he needs the physical therapist to clear my biomechanics so I can return to running.  My physical therapist said they don't do that, so my doctor gave me a referral to come here instead. 

Abby: Wait.  WHAT????

Bobby: Can you test me so the doctor will know I can get back to running?  I feel a lot better.

SO MANY THOUGHTS running through my head.  Primarily - what did your previous physical therapist do if they didn't look at your biomechanics?  Is that really what happened? 

This person came to me after having physical therapy for several weeks because they had experienced pain while running.  He had done all of his prescribed exercises and was now pain free with walking outside of the boot, but returned to the referring doctor for clearance. At no point during the rehab process had he ever been on a treadmill, tried to participate in a return to running program, or been to the track. 

What did I do?  I proceeded to conduct a complete initial evaluation of this patient - no different from any other initial evaluation I would normally do for an injury to that body region. I am a full body-focused physical therapist, so I never examine an ankle injury without looking at the lumbar spine and the hips in addition to the ankles followed by full body motions and balance. 

Bobby's parent: Wait - why are you looking at his back?  And his hips? We already did physical therapy and his leg is what hurts.  And what difference does it make that it hurts his knees when he squats... he doesn't want to squat or lift weights, we're here to get back to running. When is the biomechanics portion of this session?
Abby: Let's do that right now!

Alright... I already know from my examination that there's no way I'm clearing someone for return to running based on intolerance to a double leg squat that doesn't even hit a 90* knee flexion position.  Running is basically repeated single leg squats so if you can't double leg squat, there's got to be a problem with at least one leg in single leg squatting - but, I still need to see how the running looks because I'm going to give them a new home exercise program and need as much information as possible.  Also - the patient came with a specific request - so I'm listening to their demands and being thorough.  The more time spent in evaluation - the more effective the treatment can be later. 

This is the moment when I cut the previous physical therapist some slack and think that they knew this person should not be permitted to return to run but both the patient and parent are pushing for it and so they're sending him back to the doctor.  Who am I to judge another physical therapist I don't even know based on a patient sitting in front of me?  I fear that we, as a profession, are often guilty of blaming our colleagues without considering the whole scenario.  I'm nowhere near an expert - and I also don't have any clue what this kid looked like before 8 weeks of physical therapy.

So I put him on the treadmill and had him run.  Fortunately, it didn't hurt... but it also didn't look good.  I recorded it so I could play it back to him and his parent.  Of course there are really excellent pieces of equipment available and there are physical therapists who are highly specialized experts who work with elite-level runners.  I am not one of those therapists and I don't have any special equipement.  I know the basics of what running should look like and when I watch someone running, I can make modifications to form based on the errors they demonstrate and help them progress back to running when appropriate.

At bare minimum, all physical therapists working in outpatient orthopedics and/or sports medicine facility have the responsibility to learn how to observe and correct basic mechanics of a squat, hinge, and running pattern in order to help their patients.  I'm willing to look the other way if you can't break down throwing mechanics and specialized sport activities like gymnastics moves and ballet positions.  But the squat, hip hinge, and running patterns are essential to far too many athletes and the general population.  There are tons of courses and materials on how to do it - or you should find a colleague who can help you out.  Again - I'm no expert.  I don't spend much time studying running mechanics because the basics are pretty easy to spot once you take the time to learn those. 

I don't know if the other physical therapist ever actually said they didn't do biomechanics assessments.  Perhaps the therapist was a new grad who wasn't comfortable clearing an athlete for return to activity - as this is often a responsibility left to the physician that barred them from participation in the first place.  Regardless - because this has happened multiple times (and potentially has even happened with patients I have seen that then went to a different physical therapist... I would never even know!) - my new reoccurring segment of "What Do Physical Therapists Do" has been launched with Installment #1: We look at Mechanics. In a future post, perhaps I'll even outline some of the common faults to look for - so stay tuned for that!

Take Home Messages:
1) If you are a physical therapist - it is your job to be assessing your patients mechanics - in numerous ways - to make sure they are properly moving. 
2) If you don't know how to assess running form, there are several courses available: on Medbridge or in person, so you can learn the basics.  Truly - the basics help clear up problems in a large number of people.
3) If the basics don't fix your patients' issues, find a physical therapist nearby who focuses on running mechanics and refer.  But you should know that it is a physical therapist's job to be "the movement specialist" and as such - we need to better inform the public of what exactly we do.  You could also record your patient running (with permission - from the back and the side) and get the consensus of your clinic colleagues so you can collaborate and improve your assessment skills. Or re-evaluate the patient using a body-wide system like the SFMA to see if you're missing something.  Or send them back to the doctor to make sure an underlying pathology is not present.
4) Take the time to listen to the patient and target their treatment to the goals they have stated.  I can't always put a patient on a treadmill and watch them run at an evaluation because sometimes that isn't appropriate - but if they're going to return to sports, they're definitely going to do it at some point.
5) Find Physical Therapist colleagues who focus their energies on different areas of expertise and develop relationships with your referring doctors.  For example - I know exactly who to call when I'm looking at an athlete with pelvic floor dysfunction. And I know which doctors I can call and say - hey - I just looked at Bobby - and here's why I don't recommend he return to running at this time.

Let's fulfill the role we are intended for and serve as The Movement Specialists.

(Disclaimer: No identifying or specific patient information is being released here - as this would be breaking the law.  Names are changed, injury is different, and lots and lots of patients want to run.)