To Clam, or Not to Clam

As the battle to annihilate the coronavirus continues, everyone is faced with new realities. For me, those realities include chatting with my teenage patients on the phone, transitioning to Telehealth, and only seeing "high priority" kids while covered head to toe in PPE. The patients are still the most important part (and my favorite), but the volume is dramatically reduced so the majority of my time has been spent learning. I've also been working on the Seattle Children's Sports Physical Therapy Journal Club, summarizing papers to share with the department on a monthly basis.  The May topic, coming out tomorrow, is a collective look at these four gluteal muscle electromyography (EMG) papers:

1. DiStefano LJ et al, “Gluteal muscle activation during common therapeutic exercises.”  JOSPT 2009.
2. Boren K et al, “Electromyographic analysis of gluteus medius and gluteus maximus during rehabilitation exercises.” IJSPT 2011.
3. Macadam P et al, “An Examination of the gluteal muscle activity associated with dynamic hip abduction and hip external rotation exercise: A systematic review.” IJSPT 2015.
4. Bishop BN et al, “Electromyographic Analysis of Gluteus Maximus, Gluteus Medius, and Tensor Fascia Latae during therapeutic exercises with and without elastic resistance.” IJSPT 2018.  

Why this topic? I believe it is imperative for clinicians to be lifelong learners and that reading research is one approach to improve your skills as a clinician.  I also think it's really hard to do this, which is why I stared writing this blog - a place where I could store things I've learned and write out my thought processes.  The impetus behind this particular topic of learning boils down to two key points.

Key point number one: The Clamshell Debate.

If you've ever gone to outpatient orthopedic physical therapy, you've likely done the clamshell exercise.  It's very common and frequently patients will say they've done them in the past.  Thanks to Seattle Storm Sports Performance Coach Emily Blurton for her video demonstration:

Early in my PT career, I frequently recommended this exercise.  I had pre-made exercise programs that I used repeatedly for multiple conditions.  Now I make every program for the patient in front of me, often updating them at every session, and this exercise rarely appears. To me, the clamshell doesn't look like anything a person does in daily life or in sports. Maybe it looks like you're lifting your leg to get into a car.  But that's standing up, so maybe not.  Even worse, a lot of patients do them incorrectly and find them boring and too easy.  I don't create exceptionally difficult exercise programs, but it's a lot easier to convince someone to work on something that's challenging than on something that's simple and mundane.  And most of the time I don't really harp on having proper form - but with this exercise, is there any benefit to doing it wrong?  Biomechanically speaking, an "incorrect" squat will still give you some strength gains, but potentially not where you may want to target them.  I don't think shooting for the moon, missing, and landing amongst the stars is actually meaningful in this scenario. 

The circumstances under which I will recommend the clamshell are very specific: the patient needs to 1) have a restricted weight bearing status from the physician due to a surgery or fracture and is therefore unable to do the exercises I prefer but would still benefit from strengthening or 2) have a significant deficit in their active hip external rotation movement with available passive mobility that I want them to purposefully control. (Translation - they're too weak to do any of the other exercises I like better, but I never actually tell patients they're weak!)

I share many of my patients with coworkers who like this exercise, so we've had conversations about clamshells for years.  The biggest discussion came when I had a student who I practically forbade from assigning clams without excessive clinical reasoning of why they were a good choice for that patient. Now that I have some extra time to dig into the research, I'm looking to prove myself wrong.  Does the evidence oppose my clinical bias? And how do you explore the efficacy of an exercise?  

Point Number Two:  What research should I be reading?  

Levels of Evidence - Creative Commons CC BY-NC 3.0

In case you're not familiar with the Levels of Evidence for scientific materials, here's a very basic overview.  Certain types of research can be "trusted" more than others, particularly when you're trying to generalize data to a larger population than was actually studied.  Here's an example: Let's say that tonight at dinner, you ask your child if they likes peas.  If they say no, can you now conclude that this single case of your own observation applies to all the kids of the same age in the USA?  Of course not. But it is your expert opinion that your own kid does not like peas and you understand how that data applies in your household.  Now what if you took a survey of your kid and your two next-door neighbors houses who happen to have seven more kids, asking all of them if they like peas.  You have more information about kids in your neighborhood and their feelings about peas, but still shouldn't make wide-spread assumptions about the whole country based on your small sample.  This would be closer to a small case study moving up the pyramid. If you surveyed your neighbors and then three other researchers did a similar study in different cities, asking fifty kids in second grade and then the same kids again in sixth grade and maybe one researcher also asks about carrots, the number of data points continues to increase and your ability to generalize information across a bigger group improves.  Now you've moved up into more of a cohort study.  

This is a very simplistic demonstration, but sometimes simple demonstrates a major point.  Right now with the Coronavirus Pandemic, small studies are being smeared all over the media without sufficient data and with incorrect descriptions.  It's a good time to point out that you need to be cautious about how you interpret what you read.  Notice at the top of the pyramid sits "systematic review." A systematic review takes multiple research papers into account to accumulate more data points to try to make conclusions.  It is based on a researcher compiling data from other researcher's published works.  Each individual study may not have done the same research, but their data overlaps and new conclusions are drawn from having more data points. I DID NOT USE SCIENTIFIC RIGOR in my collection of resources for this blog post and I have minimal experience in data analysis, so I'm certain there are flaws in what I've found by summarizing these four papers.  However, I basically (unintentionally) created a mini systematic review by reading four different papers (including one which was also a systematic review!). 

I collect articles to read in the future. This collection was one reason behind starting a journal club! I've previously written about the anti-library where you collect resources to learn about the things you know you don't know here. Along with my anti-library, I also have folders of papers I've previously read. I had already read Dr. Lindsay DiStefano's Glute EMG paper (the first in the list) which was probably the nail in the coffin for clamshells for me. Imagine assuming that all kids don't like peas because one kid said they didn't?  I've basically assumed that clamshells are a poor quality exercise based on the findings of one paper that studied 21 participants doing 12 exercises.  Dr. DiStefano was my research advisor in PT School so I almost always read her publications, or have them saved for the future. (Bias Alert!)  So I need more data points! I searched for more recent Glute EMG papers to compare to hers and found three more, intentionally choosing papers that included the clam shell exercise and ultimately including one with a somewhat contrary view.  Now the data I'm considering reflects over 500 participants and many more exercises including multiple variations of the clamshell.

EMG studies are used to understand muscle activity during movement.  Not only are these papers valuable, but they can also influence patient care by helping to better understand what exercises target which muscles.  I've previously hinted at reading EMG studies with regard to the shoulder here, and for sure that knowledge changed my PT practice for post-op shoulder patients. EMG studies aren't perfect, but by looking at a collection of them, you can assume similar risk of error for each study.  Participants in these papers were first assessed for their maximal volitional isometric contraction (MVIC) (aka how strong they were for a specific muscle).  Then, by placing sticky electrode sensors on the skin at certain locations, measurements of muscle activity were taken with each exercises and compared to the maximal strength possible for that person. For an exercise to improve strength, the exercise must elicit at least 40-60 % of maximal strength (MVIC) for gains to occur.  

Here's what the papers found:
DiStefano et al: The top exercises for glute medius based on % MVIC were side-lying hip abduction (81%), single limb squat (64%), lateral band walk (61%) and for the glute maximus were single limb squat (59 %) and single limb deadlift (59%). Clamshell exercises (depending on hip flexion position) were shown to have glute medius activation of: 38-40% MVIC and glute maximus activation of 34-39% MVIC.  (Clamshells don't pass the 40% minimum cut point which has been my rationale to discontinue using them in the clinic). Other exercises were examined in the study, but since they did not cross the 40% MVIC threshold, they are omitted here.

The Boren study used a cut-point of 70% MVIC as the minimum acceptable for strengthening and examined a larger variety of exercises. Glute med exercises with >70% (MVIC) were the side plank with hip abduction (103.11% bottom leg, 88.82% top leg), single leg squat (82.86%), clamshell variation #4 hold top leg in full hip extension while internally rotating (76.88%), and prone plank with hip extension (75.13%).  For the gluteus maximus, plank with hip extension (106.22%), glute squeeze (80.72%), side plank with hip abduction top leg (72.87%), bottom leg (70.96%) single leg squat (70.31%).  This paper suggested that the best exercises to target both glute med and glute max were the prone plank with hip extension, side-planks with hip abduction, and single limb squats.

The clamshell exercise had four variations in the Boren paper. Of these variations, #4 described above was the only option to reach their defined threshold of >70%.  If you use the criteria of 40-60% outlined in the DiStefano paper, all the clamshell variations would meet that target as sufficient for strenghtening for the glute med, but only the standard clamshell works for the glute max at 53.10% with other variations all below 30% MVIC.

The Systematic Review by Macadam et al reviews multiple papers and breaks down exercises by body position.  The cross-over step up and lateral step up had the highest average glute max and glute med % MVIC.  Pelvic drop, sidestepping with hip internally rotated and band at the ankle, standing hip abduction variations, rotational single leg squat and transverse lunges all had glute med % MVIC over 40%.  Standing hip abduction, rotational single leg squats and transverse lunges also had % MVIC over 40% for glute max. 

In sidelying, side planks with hip abduction had the highest average glute max and glute med % MVIC. (That exercise is really hard, though, and wouldn't actually be appropriate for the majority of my patients.)  The paper examined 13 clamshell variations including the standard hip external rotation and others.  In one study, three clam variations (not the standard hip external rotation) had average glute med % MVIC over 60% but other studies had clamshell averages in the 30% range.  From this paper, I can start to ease up on my thoughts that patients do the clamshell incorrectly - and more that they're just creating their own variation.

And finally, Bishop et al compared glute med and glute max EMG to tensor fascia latae (TFL) EMG creating a "Glute to TFL Index."  The TFL and gluteus maximus both insert on to the iliotibial band and contribute to hip abduction.  The TFL is sometimes considered to be a contributor to low back and lower extremity pains and/or injuries and may increase in tone or "tightness" to compensate for gluteal deficits.  Bishops "Glute to TFL Index" findings were that the clamshell with resistance was 99.54 and the clamshell without resistance was 87.89 meaning that the gluteal muscles were selectively used for these exercises much more than the TFL.  The clamshell exercises far surpassed all the other tested exercises in this study with the next best exercise being the bridge with resistance at 48.86 and prone hip extension with 48.57, both about half of the clamshell values.  Thus, this paper recommends use of the clamshell exercise as a glute-targeting exercise that does not incorporate the TFL.  To these findings, I'll add another dose of bias. Does this really matter?  Does the Glute to TFL Index have clinical meaning?  I'm not sure because I don't know if I really want to "turn off" the TFL. I'll let the clams have this one. 

Free photo 5470017 © Pavel Losevsky - Dreamstime.com

In the end, I haven't been convinced.  A healthy dose of confirmation bias potentially sprinkled with some self-serving bias may contribute to that decision, but to me, the evidence seems clear. Maybe I'll be nicer to those who know that the clamshell has the higher glute to TFL index, but without that rationale, these papers suggest many other glute strengthening exercises.  For sure, I'm open to hearing alternative opinions. Are you team clamshell?  Or team ANYTHING ELSE!  I use prone glute squeezes more often than I use clamshells.  And I'm incredibly grateful for my coworkers who challenge me to think about these topics. 

(Again - this is an abbreviated summary of the results sections of the papers.  More information looking at the discussions and limitations and other aspects of the research is available if you'd like more!  For the full written summary for Seattle Children's Journal Club, go ahead and email abby.gordon@seattlechildrens.org and I can send it any time). 

New WNBA Injury Data Published!

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

Presenting at Seattle Children's Sports Symposium

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

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

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

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

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

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

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

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.  

Resilience

Resilience.  Major Buzzword.  Everyone seems to be talking about it.  "The capacity to recover quickly from difficulties; toughness."  Particularly in the wake of the recent helicopter crash that ended the life of Kobe and Gianna Bryant and reflecting on Kobe's basketball career.  Resilience is a psychological principle.  Can you cope?  Can you face the struggles in your daily life?  Can you manage conflict and overcome tragedy or trauma?  

You can see it when you look around you, to some degree.  A friend just summitted Mount Kilimanjaro.  Just got on a plane in the US, headed to Tanzania, Africa, and then climbed to the 19,308 foot high summit.  I'd say that takes resilience.   I work with patients every day who are overcoming injuries, surgeries, physical pain, chronic conditions, family struggles... and more.  I see resilience in front of me all the time.

This year, Seattle Children's hosted a leadership conference where Dr. Bertice Berry was the keynote speaker who spoke about Resilience.  She later presented to a remote Seattle Children's staff about Resiliency Connections.  So in the past month I've listened to Dr. Berry speak about resilience twice, and it seemed like a fitting topic this week.

When asked what Dr. Berry would choose as her dream job, she said she wanted the title of "Chief Inspirational Officer."  That sounds like a giant undertaking. The responsibility to inspire staff to improve their life on a day to day basis is not something Dr. Berry takes lightly.  I have the challenge of motivating and/or inspiring (definitely not the same, though sometimes both are needed) patients every day and this is hard!

Here are some things I took from Dr. Berry's presentation.  

First, identify your own purpose and identify your daily intentions.  This could be in your personal ife or in your professional world.  Consider "Why me, here, now?" Why am I here, helping this particular person with their physical therapy today?  How can I make this the best experience for both the patient and for myself so that they have the optimal outcome.  Why is it important to me that I do this?  How can I make a difference in my coworkers' lives, in my patients' lives, and in my own life? 

Second, have I given enough of myself today?  There were many memorable quotes from Dr. Berry's presentations, but one in particular was "you feel poor when you're not able to give."  And I agree.  I struggle the most when I'm facing a patient I can't help. I get frustrated with patients who have conditions that don't have a positive outcome.  I know that I can't help everyone.  I am constantly grateful that I am able to help anyone.  My usual intention is to help my patients learn to help themselves.  I don't like the idea of fixing people or that they need fixing.  Patients, even those with injuries, diseases, or conditions, are still humans and they are not broken.  They are filled with life, experience, and resilience.  Sometimes they may need a little guidance in harnessing their inner drives and motivations.  

Dr. Bertice Berry on remote feed at Seattle Children's

And third, the need for human connection. Dr. Berry said, “You can’t be well without connecting.  You can’t help others be well if you’re not well yourself.”  As a healthcare provider, the amount of time you spend giving of yourself is a lot.  You need to find ways to take a little bit too, to refill your cup or recharge your batteries - whichever metaphor you prefer.  There is a reason why people gather into communities, why the family unit has so much value for many cultures, why prayer is regularly participated in collectively.  A meal can be eaten alone, but is it ever as good as it is with good company? Prayer can be done individually, but doing so in a community elevate the spirit differently. Is singing alone in the shower the same as singing in your car with your best friends?  I find, particularly when I'm working with patients experiencing chronic pain, that they have started to isolate themselves.  They've stopped hanging out with friends, sometimes have stopped going to school, they withdraw from their family members, and they sometimes even say out loud that they don't like people.  It's far easier to suffer alone than to hear others living their lives despite your suffering.  But re-integrating into a community, finding people with shared interests and beliefs, and increasing interaction helps drag people out of that loneliness and into the light. 

As a physical therapist who values therapeutic alliance first and foremost, before my patient care really gets underway, I prioritize connection.  If my patient is not interacting with very many people, my role as their PT may be even bigger than guiding them in exercise.  Showing interest in their life, who they are as a person beyond their pain circumstances, and simply listening may have a much bigger impact on them.  Dr. Berry emphatically encouraged healthcare providers to connect with their patients.  Find the common ground.  Don't confuse your own vulnerability with authenticity.  "Nothing sucks the energy out of you more than being someone other than who you truly are."  Share your experiences to help them find their paths. 

Whether you're mourning the loss of Kobe and Gianna Bryant or someone in your personal life, or you're facing an obstacle or tragedy that has got you down, know that you have resilience inside of you. Know that you're not alone, you just might need to look around to see who else is on your team.  But look and you will find support in the most interesting places.  Maybe it's your dog or your stuffed animal or your online blog that is primarily just read by your mom, like mine.  Know that I'm rooting for you. Hopefully you can look around and find that you have enough inspirational and motivational people around you to move in the right direction.  

Thank you, Dr. Berry.  

“When you walk with purpose, you collide with destiny.”

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.