Book Alert! The Gift of Pain

Hello, blog readers!  I'm realizing now that I never concluded the cross country road trip blog posts several weeks ago.  I must have been so excited to arrive in Connecticut to see my family, it slipped my mind.  Kristen posted about the end of our journey here for anyone who thought we fell off the face of the Earth.  I flew back cradling a container of Clorox Wipes like they were my newborn baby, extensively cleaning my whole seating area, and, because I had no alternative, an entire bathroom of the plane. I'll send you the cleaning bill, Alaska Airlines!  Now I'm back home in Seattle, and I returned to a huge stack of books and audiobook CDs waiting for me at the library pickup as the world is slowly starting to open back up!

On January 6, 2020, before we knew about the COVID-19 Global Pandemic and had masks perpetually glued to our chins, while there was still air in the lungs of Breonna Taylor, I wrote my first blog post of 2020 entitled "I'm a Book Nerd."  I outlined six books I wanted to read this year related to PT and was already underway reading "The Graded Motor Imagery Handbook" - which I highly recommend to PTs, particularly those who work with patients experiencing chronic pain.  On my list were five more books, but with the closure of the library and my decision to buy a condo during a global pandemic limiting me from spending money to buy books, I couldn't get the books I intended to read.  I've been reading A LOT of alternative books since then, and with the re-opening of the library, I finally dove into "The Gift of Pain: Why We Hurt and What We Can Do About It" by Dr. Paul Brand and Philip Yancey, previously titled "The Gift Nobody Wants." 

The introduction was written by Dr. C. Everett Koop who served as the US Surgeon General from 1982-1989.  Dr. Koop starts the book off with a quote that resonated with me - and which I whole-heartedly believe in as a clinician - "When you examine an abdomen, watch the patient's face, not his belly."  I'm not the right person to say if the eyes are truly the window to the soul, but for sure I believe that the eyes are a window of truth with regard to pain.  My patients experiencing pain show their experience with a crinkled brow or looking away, sometimes covering their eyes, and on the rarest of occasions, tears.  

I must not have read a synopsis about the book prior to adding it to my list, because I was surprised to read the first pages of the book... a heartbreaking story about a little girl who genetically could not experience pain. Dr. Paul Brand was a hand surgeon whose career focused on patients with leprosy, a condition characterized by the absence of the pain experience.  Pain, after all, is an experience.  It is interpreted differently by each person and is dependent on unique understandings of- and interactions with- the environment.  And so, a four year old girl who could not experience pain tries to find ways to interact with her environment, ultimately participating in self-mutilation of her fingers and stepping on nails without awareness and continuing to walk on them.  For so many people, we try to find ways to get rid of pain, but as I've learned working in the Seattle Children's Pain Medicine Clinic, the goal often needs to be to better understand pain and learn how to optimally function despite it.  Too many people need to learn how to embrace their pain because rejecting pain allows these negative sensations to dramatically interfere with life.  

The book is a memoir of Dr. Brand's life in parallel to his journey to understand pain.  He begins with his childhood experiences in India, watching his father serve as a Missionary who also provided medical care to the local villagers.  Later he describes his schooling and career, in London during war time, and developing into a hand surgeon ultimately devoting much of his career to patients with leprosy. There are cultural influences of different world regions and comparisons between medical and community practices in India versus the United States, interactions with nature and animals and their use in scientific research, and vivid descriptions of Dr. Brand's unique interactions with pain.  In some ways it reminded me of the book we read in PT School for Cultural Competency called "The Spirit Catches You and You Fall Down," which was also an interesting approach at looking at the American Medical Model and how it conflicts with the beliefs and practices of different cultures. 

Free photo 96827 © Chrisharvey - Dreamstime.com

This book was published in the 1990's, but it's describing Dr. Brand's understanding of pain from at least 40 years of patient care.  I was repeatedly surprised at how deeply he understood pain, and the ways he tried to apply his knowledge to various conditions such as the peripheral neuropathy commonly observed in diabetics or HIV/AIDS. The book explores fundamentals about how the brain and nervous system interact, stigmatization of people who look different than "the norm," how Dr. Brand learned to conduct surgeries by operating on cadavers because the procedures didn't yet exist to help his patients, and some incredible medical successes. The stories are simultaneously heart warming and gut-wrenching, the full spectrum of emotions.  I'm six years into my PT career and this book helped me to see how I'm really only beginning to touch the surface of learning about pain and how important the biopsychosocial model of practice truly is.  How different my patient care could have been if I had known sooner! It's no wonder groups like the Level Up Initiative have been pushing for healthcare transformation... healthcare education too frequently misses the mark on the importance of therapeutic alliance and bedside manner. Medicine and the understanding of the human body has advanced considerably since the time Dr. Brand treated patients, however we, the modern day healthcare providers, have so much to learn about these foundational concepts. 

Several stories were memorable, but one that fit closely into physical therapy was when Dr. Brand's patients had successful surgeries on their hands, restoring function previously thought to have been permanently lost, only to come back a few months later with severe wounds on their newly functioning extremities.  Dr. Brand would carefully bandage the patients and they would heal, but then they would have recurring wounds, often in similar patterns.  He took the time to observe their daily activities - noticing that one gentleman was using a hammer that had a splinter in its handle that he could not feel - so the repeated use of the hammer was breaking down his skin.  Another instance found that a man was reading in his bed at night time and would go to turn off his lamp, night after night brushing some of his knuckles against a hot piece of glass on the lamp, and that this was slowly burning his flesh.  In a third instance, one that Dr. Brand felt was most challenging to figure out, some of the patients had rats chewing on their fingers in their sleep, which through the introduction of cats into their housing fixed the problem of their hand wounds.  All of these patients - and the world at large - thought that having the diagnosis of leprosy meant that fingers and toes would spontaneously fall off, that the tissues were somehow bad, and that the disease was highly contagious.  Dr. Brand was able to solve so many problems for his patients to improve their quality of life and provide hope to this patient population.

The book goes into some detail with regard to Dr. Brand's three stages of the pain system - how first a "danger" message must be received from the environment, then this signal is transmitted to the spinal cord and lower portion of the brain to be filtered and assessed - ultimately reaching the higher portion of the brain where a response is decided upon.  Pain occurs when "the entire cycle of signal, message, response has been completed."  He provides examples of how pain can be "stopped" by interrupting the cycle at each stage, and how much the mind and learned experiences can impact the third stage and  recovery from pain.  

I think reading this book will certainly improve my understanding of pain, though some of the newer materials I have read go into some different detail, this is a much simpler read with memorable anecdotes.  I can't recommend it highly enough for newer physical therapists to emphasize a different way of thinking than our classical training likely provided. If you have any interest in science, medical stories, pain, and human compassion - check it out.  Brand includes the definition of Compassion early in the book: latin roots are com + pati meaning "to suffer with."  A compassionate healthcare provider truly does suffer with their patients. We may not feel your physical pain, but our hearts connect to your experience, and we care about you.  To some degree, suffering has an element of choice. I hope to help reduce the suffering of my patients, and I'm so glad this book was recommended to me!

Wide Open Wednesday and Tourist Thursday

Kristen’s hard work blogging continues. Days 4, 5, and 6 are completed. I’m not sure where she finds the energy as I basically collapse into a coma at the end of the day and am minutes from doing so again right now. 

Wednesday’s Day 4 adventures on Kristen’s blog are here. I earned my keep driving about 500 miles through half of Wyoming and most of South Dakota. I didn’t think this drive was as bad as everyone said it would be- though for sure it was much flatter and far less scenic than our previous few days. I enjoyed the sporadic surprises along the way. 

We stopped at Mount Rushmore and the Corn Palace which were both cool.  I love seeing the unique features of basketball arenas and this one was for sure the most unique arena I’ve ever seen. I’m missing the WNBA season pretty fiercely so a moment in my happy place (a basketball arena) was an awesome boost to a day of driving over 700 miles. We had plenty of time to discuss how nobody here really seems to be doing anything differently regarding the Coronavirus- except there’s probably more hand sanitizer available than usual. 

Wednesday we crossed the half way point. We listened to lots of music and some audio books. Both of us took car naps. We passed through Hartford, South Dakota which made me feel a lot closer to home. We didn’t hit the cow that was in the middle of the highway... I yelped a bit when I came upon it and may have awakened Kristen in shock.

(Please note the previously mentioned bug cemetery windshield, too).

Then Tourist Thursday came about where we did a bit less driving with a crash course in Chicago tourism with a visit to Navy Pier, the Cloud Gate aka the bean, and Giordano’s pizza for some deep dish. Unfortunately the Air BnB we had booked in South Bend, Indiana was a hot mess and after maybe 5 minutes walking around it and thinking we might not live to see the East Coast if we stayed, we hit the road and kept driving while finding a hotel room to crash in. I guess I’ll have to save Touchdown Jesus at Notre Dame for another time. I’ve still never seen that campus despite driving through here at least 3 times in my life. Somehow I never ended up there with UConn Women’s Basketball... and this visit tells me that maybe I’m just not meant to see what the Fighting Irish campus has to offer.  Kristen’s more detailed post is here.

Today we completed Indiana and booked it across Ohio and into Central Pennsylvania with the major highlight being a family visit.  Overall we’re making great time, haven’t run out of things to talk about, and are about an hour and a half away from splitting up to our final destinations. See ya tomorrow, CT!

Yellowstone and Grand Teton Tuesday

Day 3 went by so fast!  We didn’t drive very far but we explored two National Parks- Yellowstone and Grand Teton- both really awesome, though we both preferred Grand Teton. This has been my first visit to Wyoming and it was certainly a unique place to visit. 

Here’s the link to Kristen’s Day 3 post for you to check out! And a video clip from each park. 

Montana Monday

Hey again!  As previously discussed yesterday in this post, my friend Kristen and I are driving from Seattle to the East Coast. She’s an adventure blogger so she’s been writing all about our experiences and I’m a day behind her in reposting them. Here’s her post from yesterday.  Yesterday we spent the day in Montana with the highlight being Glacier National Park.

Feel free to follow along our journey... or text us. We’ve got 2000+ miles still to go!

Cross Country Road Trip Day 1!

Happy summer everyone!  Whatever summer looks like during a global healthcare and national humanity pandemic.  I’ve really been struggling to write blog posts the past several weeks because sharing PT knowledge isn’t as important to me as the time I’ve spent reading about the coronavirus and the systemic racism pervading the US. 

And then, I learned the sad news that my coworker pal, Kristen, (Who I went to Africa with and have previously written blog posts about) was leaving Seattle Children’s to join the PT crew at Boston Children’s Hospital. But moving during a global pandemic, which I did during May, is more challenging than usual. She wanted to drive but it’s so far to go alone, and so our plan to road trip across the country was born.  

Road tripping isn’t one of my usual blog posting topics, but Kristen writes about her adventures, so I’m sharing hers as a blog of our trip. Check out her day 1 post from yesterday at this link and make sure to comment on her posts and answer her question of the day! 

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.