Monday, August 5, 2019

The Government is After Me!

Photo Credit: Michelle Vieira at London 2012 Olympics
This morning I have a long layover at JFK airport en route to Africa!  As I've been observing TSA, watching the news sitting in horribly uncomfortable chairs, and seeing what's going on in the world, it got me thinking a little bit about our government. Earlier this year, I was home in Connecticut visiting my family when I received a letter stating that I had been selected for Jury Duty.  In the State of Connecticut.  Where I have not lived for the past 4.5 years.  Fortunately, it was easy for them to verify that I no longer live there and was able to get out of it - but that's my second Jury Duty Selection and some people have never been picked!  How does this happen?  What fortunate - or unfortunate - thing have I done to put me on a list saying I should serve when others have not been chosen?

My first jury duty selection was in the summer of 2004, right after my freshman year of college.  It was a trial where a man had been running in the early morning and he had been struck by a car resulting in severe, long-lasting injuries.  The runner was suing the driver of the car, who happened to be the newspaper delivery guy.  He was also suing the newspaper company and their insurance company.  I spent 5 days in the New Haven County Courthouse listening to testimony, reviewing medical bills and photos of the injuries. This was long before I was a physical therapist, so while I was a bit annoyed to be missing my summer vacation, my job paid me for the time and it was definitely a better learning experience than being at work in the bakery at Everybody's Supermarket would have been.

Anyways, I returned to Seattle after a great snowy East Coast trip and arrived to find a letter from the State of Washington Department of Health that my PT License was being audited and that I needed to show proof of all of my continuing education.  I was certain the government was out to get me!

So... for my fellow PTs - in or out of Washington State, here are a few pointers, should this happen to you, because I found the letter indicating my audit - and the details of what was needed- to be quite lacking.
1) Keep track of your continuing education!  Names of courses and the presenters, dates and locations of where you took them, number of hours, a list of objectives for the course, and keep the copies of the certificates.  My certificates are in a binder and I have a google doc with my annual course titles/hours already, but I didn't have all the required information that was asked of me.  For example, I've talked about the courses I took with Mike Reinold and Lenny Macrina a few times on the blog like here and here, but I couldn't have told you their credentials and didn't have access to written objectives for the two courses I took from them.  Fortunately, their credentials were listed on the certificates and they were more than willing to send me a list of objectives since their classes have been approved by continuing education review boards.  Medbridge also supplies all this information on all of their certificates.
2) Know the rules of your state.  Washington does not require verification of your courses for PT.  Neither does Connecticut.  Three states (Maine, Massachusetts, and South Dakota, which I wrote about here do not require continuing education at all.  But if you practice in those states and then try to switch states, this may cause you some problems in transitioning your license elsewhere. (Also- how are you practicing physical therapy without participating in continuing education?!? My education was great at UConn but seriously- you’re left needing to know so much more!) You may have specific things you need to have specific education for, varying by state. Examples of unique circumstances that some states have for continuing education:
  • Suicide prevention training - required in Washington, course is available on Medbridge - probably a really good thing for any physical therapist to have!
  • Spine manipulation - can get a special endorsement in the state of Washington, which I hold, and which has its own continuing education requirements. If I had to guess, this is the reason why I was audited... but maybe it's just random.
  • Dry Needling - not permitted in Washington, but is allowed in many other states.  My understanding is that dry needling certifications tend to be regulated carefully in some states.
  • Somewhat related - if you are a Certified Strength and Conditioning Coach through the NSCA, you cannot use almost any physical therapy courses for your continuing education for your CSCS.  They have a list, here, which includes First Aid/CPR as an option - which we cannot claim for continuing education for our PT licenses.
If you're in Washington, the letter for audit basically says you should read the laws and see what applies to you and submit sufficient information to cover your own requirements.  Here's where you would go to find that information:
1) Physical Therapy Requirements: here for your initial license and here for continuing education requirements
2) Spine Manipulation Endorsement Requirements: here
3) Dry needling is not permitted in the state of Washington under the Physical Therapist practice act,, so we don't have regulations for it. 

I asked a lot of PTs if they've ever been audited... zero coworkers or PT friends have been, but some had friends or family members who've had to submit their information.  Overall, the process wasn't really that difficult because I have all my certificates and track my hours - plus I have more than enough hours for everything I need.

Ultimately, this is my PSA that you should keep track of - at the very least - the minimum requirements you need for your license to remain active - because this is a real thing and to track those things down later would have been much more difficult. 

Abby 2 - Government 0.   See ya in two weeks, America!

Monday, July 29, 2019

Vaccination for Africa!

In just a few days, I’m departing on an adventure, heading to Africa!   I’m headed specifically to Nairobi, Kenya for a day followed by two weeks in Arusha, Tanzania ending with a Safari!!!!  Thanks to my coworker pal Kristen who writes this blog (even more specifically, has several posts from her previous trips to Africa, here)... and we’re joining one of her PT School professors and 7 students from Stony Brook University to do some physical therapy-related work. I don’t have the details of what we’ll be doing yet- so stay tuned for the post-Africa blog posts for that... but the preparations for the trip have been very interesting and I thought I’d write about the medical preparations for the journey - along with some thoughts on vaccination.

From: http://pcwww.liv.ac.uk/epidemics/MAL_geography.htm
Let's talk about medications.  Thanks to Virginia Mason’s Infectious Disease Department- not only was I able to receive the shots and prescriptions I needed, but they also explained many of the possible risks and made recommendations for me. They collected my dates and destinations of travel in advance, prepared a stack of pamphlets for me, and had the shots and prescriptions I needed ready to go.  I now have a whole pharmacy packed based on things that my body might encounter that it doesn't generally experience at home. Specifically- Tanzania is in the malaria belt and Kenya has an escalated risk for contracting yellow fever. And so- I have malaria medications and I had a yellow fever vaccine this week. The provider who organized all my medical care for these travels, Lisa Roberts PA-C was very thorough and presented the options for all the medications - such as discussing my choices for malaria medicines because some of them can be hallucinogenic.

Some interesting facts about these diseases:
Malaria:
1) Link: There are five types of malaria parasites called plasmodium.  One type, Plasmodium Falciparum, can be life threatening and induce liver failure, kidney failure, and coma.  This is generally the type that you take preventive mediation for when traveling.
2) Link: Malaria is transmitted by mosquitos, so using bug repellent containing DEET, long sleeves and pants, and taking preventive medications are all useful preparations. The particular type of mosquito, the Anopheles Mosquito, cannot survive in climates cooler than 68*F, so since central Africa is so warm, this is a common region for the disease.  As global warming continues, the malaria belt is expanding.  Even though the United States has successfully managed to reduce malaria cases, we do house these mosquitos, so there is always the risk that malaria can become a bigger problem here at home.
3) Link: There is a malaria vaccine, but it has a low efficacy and requires four injections... so I'm not immunized, I'm taking preventive medications. The reason for this is that the DNA of that plasmodium reproduces so fast, it can build resistance - just like we've seen with antibiotics resulting in things like methicillin resistant staphylococcus aureus (MRSA - the SuperBug) which, by means of evolution do not respond to the usual medications.  I'm so glad I read "The Origin of Species" by Charles Darwin, and wrote about it here.

Yellow Fever:
1) Link: Yellow Fever is also transmitted by mosquitos.  About 15% of those who are infected will have severe symptoms including shock, organ failure, and possible death.
2) Link:  The vaccine against yellow fever is considered to be life-long protection and 99% effective.  and is a live vaccine, which means that scientists took the actual disease, weakened it, and then it gets injected into you to build up immunity to it. There is also a shortage of the vaccine with limited number of places where you can go to get one - so if you're looking to travel, plan ahead!  You need a specific yellow card marked with your immunization in some cases - for example if you spend time in Kenya before going to Tanzania, like we are, you need the shot.

In addition to malaria and yellow fever, we also discussed risks for hepatitis, rabies, measles, mumps, rubella, influenza, and diphtheria, along with multiple symptoms that could require treatment, particularly related to gastro-intestinal distress which I won't go into detail about but which also included some shots and medicines.

What is a vaccine, anyways?  A vaccine is a medicine used to prepare your immune system to fight a disease in case it ever comes into contact with it.  Our body fights off disease by using a system that requires exposure to something to build up a defense system.  The vaccine is the first exposure to a disease, usually a weakened or dead version of it, so the body can recognize invaders and be prepared to fight.  There is considerable controversy around the country with some parents believing that vaccines are dangerous - or they don't believe in inoculation for a variety of reasons.

While I've been going through these preparations and getting additional immunizations beyond the ones I've had for public schooling, college, graduate school, working on an ambulance and now working in a hospital-based system, Seattle Children's and many other places around the country, have been facing increased episodes of cases of measles. Seattle Children's publicized exposures there here and this article describes the over 1,000 cases identified in the US this year, a considerable increase since measles was considered to be eradicated in 2000.  Measles is a highly contagious disease spread through coughing or sneezing or bodily fluids of infected people and does not have a cure.  A contagious person will likely infect 90% of the non-immunized people they come into contact with.  There is a high risk of fatality from measles because of the complications of the condition - immune compromise and opportunistic infections like pneumonia.  The vaccine is only 97% effective, so even those who are immunized aren't perfectly protected, but because of the high risk, it's essential that people vaccinate their children.  I urge everyone to read about the signs and symptoms of measles, particularly if you are in an area where there has been a spike in cases as it looks like there is a current epidemic occurring or if you are a healthcare provider.

Volunteering Emergency Response in Israel in 2006
Several cases of measles in Washington have been linked back to being at Seattle-Tacoma International Airport, where I'll be headed to depart for Africa in just a few days.  Interestingly, I also found this article looking at the measles epidemic occurring on the east coast, reporting cases in New York in Orthodox Jews who do not inoculate their children and who had recently traveled from Israel (which has been having an outbreak as well).  This article also discusses the Orthodox Jews having this increase in cases.  Having been to Israel several times and lived there as a volunteer EMT in 2006, knowing that they're so advanced in their medical and technological developments, this shocked me!  Over 500 of the cases in the US are in NY in this population, and Washington is 2nd on the list.  As a Jew myself, I can't understand why the Orthodox aren't taking care of this.  It seems that some believe vaccination is against Jewish law, which is of course an interpretation of something, though I'm not sure what, because vaccines obviously did not exist at the time Jewish law was written. What is for certain part of Jewish law is to do anything that may save a life, and since vaccination can save lives, it seems to me that more Jews would support vaccination.

Even the APTA has a position on this.  Physical therapists are in a prime position to encourage families to get their immunizations as part of their regular health care.  The risks of not doing so many times could include fatality - to your own family member or to someone else.  The benefits far outweigh the risks.



Thursday, July 18, 2019

Ways to Move This Summer

Earlier this week, I had a unique opportunity to do some work with a small child, maybe about 3 years old? She wasn't my patient... it was a special circumstance...  and, though she was very, very cute, this was entirely out of my comfort zone.  Though I do work at Seattle Children's, my patient population is between ages 5-21, with the majority of them between ages 9-15.  That's right, I spend most of my day with teenagers. It's awesome.  The younger kids will still talk about Disney princesses or super heroes and the older ones can discuss books I read when I was a kid, sports, movies... nothing deep, nothing life shattering.  It is a rare occasion that an older patient comes in and discusses politics or religion or their job - though several of the younger kids talk about their church camps or youth organizations or really interesting volunteer projects they work on and some of the teenagers do work.  It's entirely different from the conversations I used to have when I worked with adults who had stress from jobs, older parents or younger children, money woes, car break downs, or deeper interests that required me to think.  A 3 year old was uncharted waters.

One does not simply sit and have a conversation with a child of this age.  This particular child didn't even really sit at all. She was constantly on the move, excited to explore the world around her, touch everything colorful in the Seattle Children's Rehab space.  I'm not sure how parents do it!?!  I'm not sure how my coworkers who do work with children this little do it!?!

Anyways, I was tasked with finding things for this little girl to do for about twenty minutes.  Fortunately, I had just read a new Community Education flyer from the Seattle Children's Sports Medicine Department entitled "35 Ways to Move Your Body This Summer."  My awesome colleagues - a rock star physician and three incredibly talented physical therapists (also team #StrongWomen) - collaborated on this project to provide families with ideas to keep moving.  (Message me or comment with email address and I'll send you the whole PDF!)  This list came in handy when trying to identify things to use with a small child - but could easily be applied to all ages - kids through adults - to find ways to stay active during the summer time - and beyond!  Here are some of my favorite suggestions from the list, and some that I used to survive working with a tiny kiddo!

1) Make an obstacle course: in the clinic we have access to lots of cool things to climb over, jump on and off of, balance on, and even a tunnel to crawl through. This is an easy thing for children to help build and then use to keep moving, and then rearranged.  Or, perhaps you're going to the playground and using the items there to make an obstacle course.  Either way - so much delight from that little girls face with crawling through the tunnel and jumping onto colorful circle dots.
https://www.amazon.com/Discovery-Kids-Adventure-Removable-Lightweight/dp/B07BR83L6J/ref=sr_1_55_sspa?keywords=crawl+tunnel&qid=1563483750&s=gateway&sr=8-55-spons&psc=1
2) Water Play: this could be in a pool or at the beach or running through the sprinkler in your back yard.  At the beach, you can bring various toys to play with - like a beach ball or shovels and pails to build a sand castle with a moat.  If the water isn't too cold where you are, and you're going in to swim - you can also play water games, swim races, hand stands in the water, or see how long you can balance on one foot while in the water.  For me, water play is kayaking.  In fact, I wish I was in my kayak right this minute.  But there are so many other options good for kids!  In Seattle, you can rent Canoes near UW, link  or rent kayaks or paddle boards at Green Lake or multiple places on Lake Union.  Tons of the teenagers coming into the clinic have been trying out paddle boarding this summer because it's so popular here.  Endless options to get outside and keep on moving.

3) Boot Camp or 4) Circuit Training and 5) Stretching: Attached to the "35 Activities" is a list of exercises and a list of stretches. But these additional lists can be organized in tons of different ways.  For example, boot camp directs you to choose a few exercises such as jumping jacks, push ups, sit ups, running in place and you do as many as you can for a minute, and repeat the routine a few times.  This idea is similar to circuit training, a technique I commonly use in the clinic, though the intensity is a bit different.  Using a variety of stretches, you could create your own home yoga class!  Even more fun, lay a towel out in the yard and do it outside!  I've previously written about my affinity for yoga here and strongly feel that though the intent is usually stretching, several stretches require you to work hard and also improve your strength and overall fitness. The list goes on with many ideas for games using these exercises such as assigning each one a letter, and then spelling out your name or a word.

So many great suggestions, and I've only touched the surface of the list from my coworkers!  This resource is really great - I can't wait to share it.  Don't forget about the tons of ways you can make walking fun: go somewhere different to explore a new neighborhood, make a list of objects to find (scavenger hunt) and see how many you find, walk your dog, go with friends, do it in the woods or at the beach, or make a game out of it like dancing every time you see a car drive by you.  Ride your bike or a skateboard or a scooter.  Also, a pack of sidewalk chalk makes your driveway into an endless number of games - like four square or hop scotch or into a race track.  My niece and nephew used to make a race track in their driveway with lava areas they had to avoid or stop signs or change of direction arrows that they drew before riding scooters or bikes or skates on it.

All these suggestions are a great follow up to my post last week about the negative impact of early sport specialization.  That post discussed concerns with athletes starting to play only one sport too young.  Though there is varying information, it is recommended that kids should play multiple sports until at least finishing middle school, probably somewhere around age 14.  This 3 year old had NO problem with wanting to climb on things, jump on things, stack cones, hop, skip, jump, squat, throw, kick... you name it, there was a TON of variety.  I don't think you need to be participating in multiple organized sports - you just need to move in more ways.  For example, strength training in an organized manner rather than playing your sport year-round could be a great way to improve your fitness and make a more skilled athlete.  Or, have a dance party with your friends... it's certain to look different than your usual sports.

Friday, July 12, 2019

Megan Rapinoe Used to Hoop, too!

Summer is here!  The barbecues are starting, fireworks and mini American flags are on sale everywhere, and the sun is finally shining in Seattle with WNBA basketball under way.  I've taken the kayak out already and saw some seals and I've lost and found my sunglasses at least three times with the bipolar nature of the weather in Seattle. I've been working on a blog post about sport specialization for a while, and it has been  moving too slowly for me - primarily because I've been spending a lot less time at my computer and a lot more time in the sunshine when it comes out, but also because other topics just keep popping up that I want to write about. And then I decided I really wanted to write about the United States Women's Soccer Team this week, but... that's what everyone else has been doing.  And so, I decided to combine the two.


First,  I'll start with a definition.  In 2002, Jayanthi et al defined sport specialization as "intensive, year-round training in a single sport at the exclusion of other sports."  This came along with: “The American academy of pediatrics and the American medical society for sports medicine have both discouraged sport specialization before adolescence but acknowledge that this recommendation is largely based on expert opinion...” What does it mean?  It means that medical professionals are supporting playing multiple sports, moving in multiple different ways, participating in unorganized play that isn't a sport at all - just like playing games of tag or riding bikes around the neighborhood, or climbing a tree - so that the body moves in different ways.  

There are considerable benefits to playing sports.  Health benefits, of course, including improved heart rate and blood pressure, cardiovascular endurance, and muscular strength.  There are also mental health benefits, particularly with team sports - but also with individual sports - like community interactions, competitive spirit, sportsmanship, and having a support system.  But there are also risks.  That same article from Jayanthi also found that youth athletes with a higher socioeconomic status were more likely to sport specialize and were also more likely to experience more serious overuse injuries than lower socioeconomic status athletes.  It was also found that those youth athletes who participated in team sports tended to have less frequent overuse injuries than individual sports.

Myer et al provides some interesting statistics about the success from sport specialization: Approximately 30% of American kids specialize in one sport with the goal of earning a scholarship and reaching the professional level in that sport, but only .2-.5% make it to the elite levels. Many parents and, more dangerously, coaches believe that focusing on one sport is the way to reaching this goal.  But using the same patterns over and over again may not help develop resiliency and strength in other movement patterns. 

Some quotes from that paper:

"Single-sport specialization was first reported in Eastern Europe with athletes involved in individual sports such as gymnastics, swimming, diving, and figure skating."

"Vaeyens and colleagues59 reviewed the training history of 2004 Olympians and found that the mean age of sport initiation was 11.5 years."

"At the collegiate level, a study of National Collegiate Athletic Association (NCAA) Division 1 athletes at one university found that 70% did not specialize in their sport until at least age 12 years, and 88% had participated in more than one sport."

Since I had already been doing research for a blog post on sports specialization, I looked into the roster of the USWNT and all the other sports those athletes played - other than soccer.  Here's what I've found.

Morgan Brian played varsity basketball through her senior year of high school before specializing in soccer.

Adrianna Franch was an all star high school basketball player
Ashlyn Harris liked to surf and skateboard with her brother
Tobin Heath reportedly likes tennis and surfing
Jessica McDonald played four years of high school basketball and was a state champion and record holder in the 400m in track, also participating in the same three sports for two years of junior college before heading to North Carolina where she specialized.  The USWNT has a really long list of Tar Heels and a few Penn State Nittany Lions and Stanford Cardinal grads...I guess those would be the college power houses for women's soccer the way UConn is for women's basketball. 
Alex Morgan is listed as a multi-sport athlete.  As one of the most recognized athletes on the team, I think it's important to note that she tore her ACL when she was 17 and recovered to the extremely high level of play that she currently is at. In this chat, she says she started playing soccer around age 7 or 8, but played volleyball, basketball, and softball as well and didn't start playing club soccer until she was 14 years old.
Alyssa Naeher, my fellow Connecticut native, also played basketball in high school. 
Christen Press, (who I was insanely lucky to sit next to on a flight from Hartford to Chicago last summer in which the entire USWNT was on the plane and Sam Mewis sat behind us) played tennis and ran track before heading to Stanford for college. 
Megan Rapinoe played basketball and ran track.  
Becky Sauerbrunn also played basketball and volleyball. 


Megan Rapinoe celebrating the Storm Championship
Abby Dahlkemper, Tierna Davidson, Crystal Dunn, Julie Ertz, Lindsey Horan, Ali Krieger (did you know Krieger is German for warrior?!), Rose Lavelle, Carli Lloyd, Allie Long, Sam Mewis, Kelley O'Hara, Mallory Pugh, and Emily Sonnett - are not listed to play another sport on wikipedia, though that doesn't mean they didn't or haven't.  It most likely just means they didn't play another sport in high school and specialized before then, perhaps even playing something else through middle school.  Having ten out of 23 players noting what other sports they played until about age 18 has to help demonstrate the value in playing multiple sports!

So, what should we do about it?  We need to advocate for kids to play, to have recess, to move more, and to support participation in more than one sport.  My mentor from PT School, Lindsay DiStefano refers to this as Sport Sampling.  (I'm not sure if she coined this term, but it's the first place I ever heard it, and I like the idea - sample different activiites, find the ones you like, and move more!)  "Parents and educators should help provide opportunities for free unstructured play to improve motor skill development and youth should be encouraged to participate in a variety of sports during their growing years to influence the development of diverse motor skills" again Myer et al. 

And so, it's summer time.  Let your kids go out and play.  Run at the beach, play tag, kick a ball around, throw a frisbee, swim!  Don't let them play the same sports all year round.  And watch other sports too... like basketball, because now it's game time, and I'm off to go watch the Seattle Storm in action, hopefully with soccer star Megan Rapinoe in attendance!



Thursday, July 4, 2019

WNBA Injury Summary

Hey everyone!  Happy Fourth of July! Yesterday the Seattle Storm played their "Kid's Day" game, a tradition around the WNBA hosting games early in the day - always a rowdy event with lots of children attending games and singing along with what's going on in the arena.  Today was the first time I've ever head "Baby Shark" at a WNBA game.  I certainly hope it's the last.  If you don't know what that is, it's here for your viewing pleasure, but know that you have been warned: your day is about to be ruined. 
As the Storm Physical Therapist, I have the opportunity to work with some of the players who are injured while they rehab to get back to playing.  This season, the Storm seems to be battling a curse that started in the off-season when Breanna Stewart's ruptured Achilles which I wrote about here, followed by Sue Bird having a knee surgery that was written up in the Seattle Times here. And the list continues after that. There are articles here about Jordin Canada's injury, which she has returned from, and an article here about Jewell Loyd's ankle injury, and an article here, about Kaleena Mosqueda-Lewis injuring her ankle earlier today.  What a mess!  
But I'm not here to write about the Storm Players' injuries (affter all, there are laws against that).  Watching another player getting injured today made me reflective on the woes of the Storm this season and then start looking into the other teams to see how they're faring.  There is a site which lists WNBA injuries, here, which I used for the starting point of this research.  And so, without further ado, my research findings of injuries from around the WNBA.

ATLANTA: 
Angel McCoughtry, a 2x Olympian and WNBA All-Star tore her ACL in August 2018.  Based on typical rehab timelines, I'm not really sure why she hasn't made it back to the court by now - this article and this one from last week both say it's due to strength deficits, which would definitely be a reason to delay returning.  I previously wrote about Angel here when I saw a video of her rehab in the off-season that I found appalling.  I hope things have gotten better for her recovery since they filmed that session.  Earlier this season, Tiffany Hayes had an ankle injury that was written about by High Post Hoops here, but she's been playing through it for the past eleven games.

CHICAGO:
Katie Lou Samuelson has missed all but three games with a broken right wrist.  I recently read this article about her injury where she was working with my long-time friend and the Sky Strength and Conditioning Coach Ann Crosby about all the cardio "Lou" has been doing while she's been casted, hoping to stay in good shape for when she's cut out of the plaster and allowed to start dribbling again.  High Post Hoops also covered Katie Lou and her teammate Jamierra Faulkner who had a knee injury in this article. Faulkner tore her right ACL last July (her left ACL was injured in 2017), and like Angel in Atlanta, appears to have had some complications with her recovery delaying her return to the court.

CONNECTICUT:
Last week, Layshia Clarendon underwent surgery on her ankle, putting her on the injured list for several months.  The Sun, the team I worked for from 2007-2010, posted the news here.  If she recovers on the fastest timeline for her particular surgical procedure, she might be able to step on the court by the end of the WNBA playoffs.  But basically, she's going to be watching a lot of basketball and not playing, which is unfortunate, because she's fun to watch!  With Connecticut winning lots of games right now, if they can manage to stay healthy, I think they'll still be playing in September.  And they have one of the most experienced (and also long-time friend) Head Athletic Trainers in the WNBA, Rosemary Ragle.    

DALLAS: 
It bothers me a little bit that pregnancy is included on the injury list - but they also list players who are unavailable to their teams for overseas basketball commitment, so maybe the list should be called "players who won't dress" rather than being an injured list?  Anyways, Skylar Diggins-Smith had a baby boy in April and is set on returning to the court this season, but hasn't yet.  The team has had so many issues with players being unavailable (Skylar, Glory Johnson in the Eurobasket, and Tayler Hill about to have knee surgery - all listed here) that they were ultimately able to add NCAA WBB Player of the Year Megan Gustafson about three weeks ago.  Even USA today had a little blurb about Tayler Hill having surgery here- and they didn't have a single article during the WNBA Finals last year.  (At least they had no articles in print - maybe there were some online that I didn't see.) And Dallas has Isabelle Harrison back after suffering two concussions early in the season. 

INDIANA: 
Victoria Vivians is out with an ACL injury from overseas during the off-season and Natalie Achonwa missed a game or two with a finger injury, but otherwise, I haven't seen anything about Fever injuries. 

LAS VEGAS: 
Aces center Liz Cambage came in for the season with Achilles tendinitis but has returned to playing.  Point guard Sydney Colson also had a concussion in June but has since returned.  Another crew that's overwhelmingly staying healthier than most. 

LOS ANGELES: 
Team Super Star Candace Parker sat out the first several games of the season after a hamstring injury during a pre-season game, but has returned to the team. Alana Beard also missed about a month of the early portion of the season with a leg injury.  That's two key players missing the first month of the season - so now that they're getting back into the swing of things, it will be interesting to see if LA can turn some of their early season woes around.

MINNESOTA:
Things got so bad in Minnesota, they were approved TWO roster exemptions so they could add players because they are facing multiple season-ending injuries. Two new players on the roster after more than a third of the season is over is incredibly challenging to teach your basketball system and try to build chemistry.  They're having a lot of knee troubles.  Karima Christmas-Kelly hurt her knee and underwent surgery two days ago and is listed as out for the rest of the season. Jessica Shepard is also out for the season with an ACL injury and Seimone Augustus has not yet played in a game this season from a May knee surgery - but she is expected to return at some point.  Damiris Dantas is also out with a calf injury expected to return in about two weeks.  And we don't have to mention the absence of Maya Moore, who is not injured but is pursuing some personal ventures this season... (OK of course I had to mention her)  

NEW YORK:
The NY Liberty mostly has personnel issues due to several team members playing overseas, though they'll be returning shortly.  Rebecca Allan has a finger injury keeping her sidelined and she did not play against us in Seattle yesterday.  New York has had a lot of front office struggles in the news in past years which hopefully are improving now that they have new ownership - so maybe they deserve a break from the injury bug while they try to make positive changes in one of the few remaining cities to have an original WNBA team despite their move away from Madison Square Garden.

PHOENIX: 
In my opinion, the greatest basketball player of all time is Diana Taurasi.  She's also an exceptional human being.  Unfortunately, Diana has been sidelined all season so far following spine surgery, but is tentatively expected to return to the court this week.  Sophie Cunningham had back pain two weeks ago that limited her playing and DeWanna Bonner had an ankle injury last week, but both have returned.

WASHINGTON:
Kiara Leslie underwent a meniscus surgery at the end of May with expectations of about 3-4 months of rehab.  Kristi Toliver had an injury to her right quad and Aerial Powers had an injury to her left glute, but both have made it back to the court.  Superstar Elena Delle Donne has had some lingering issues with her knee since injuring it during the 2018 playoffs, but only missed the earliest games of the season. 

I'm sure I missed other injuries.. and the ones listed above are just the ones I found when google searching - which means these are the athletes that missed a game - or many.  Having been around teams for so long, it's easy to say that most WNBA players are battling nagging aches and pains and are getting regular treatment - either massage or chiropractic care or acupuncture or just spending time in prehab/rehab with the athletic trainer and strength and conditioning coach.  Or in the unlikely event, as I wrote about here, with their physical therapist.  

TAKE HOME MESSAGES:
1) The WNBA is experiencing a lot of injuries this season, and reviewing these articles, they're not just small injuries like ankle sprains removing athletes from 1-2 games.  These are surgical interventions and months-long rehabilitations including year-long recoveries when you consider the Achilles tear for Breanna Stewart and the ACL injuries of Angel McCoughtry and so many others.  

2) It's really hard to know if this rate of injuries and the number of "severe" injuries is more than previous years or not. It looks to me like it's definitely more, at least here in Seattle.  But, from what I've learned in the past two years having had discussions with league representatives about my interest in researching WNBA injuries is that the system by which the league collects injury data has not been monitored or really enforced in many of the previous seasons and there isn't anyone with access who can put this information together into a report. I don't have access.  Teams have to submit their injuries.  Some teams are really good about it.  Others are less diligent.  In my dream world, I'd be taking the data from all the WNBA seasons with injury information in the past and I'd be analyzing it to see what kinds of trends can be identified to try to help with injury prevention programs at the youth, high school, and collegiate levels, with particular focuse on female athletes, but it certainly would not hurt males.  I'd also be working to compare it to the NBA because their work conditions and medical equipment and support staff limitations are so different, it would be interesting to see if any correlations could be found.  Someday I'll figure out how to take this project on and develop meaningful data that can be used to help future WNBA players - and elevate the world of women's sports. Someday.  

3)  How awesome is it that there are so many more news sources reporting on the WNBA!?!?!?!  LOVE THIS!  CBS Sports even posted this article about the Connecticut Sun soaring while all the other teams are figuring out how to deal with their injuries. 

4) There are a lot of former UConn Huskies on this injury list... and while that probably isn't relevant, it is apparent.  Maybe that's because there are so many in the WNBA - or it could be several other reasons.  I won't try to suggest what it could be, but watching UConn basketball players getting injured in college and the WNBA is what drove me to go to PT School in the first place.  I'm feeling a little disheartened that there hasn't been enough progress in injury prevention in these athletes, and potentially we're doing worse in the WNBA.

5) When the Seattle Storm won the championship last season, many of the medical providers felt that the WNBA season is a marathon - not a sprint - and that the team with the least severe and least number of injuries during the season would be the last team standing.  This is part of the game in all sports.  But I'd prefer it if the last team standing, hoisting that awesome WNBA Championship trophy overhead, was the one who had the most talented basketball players with the best chemistry and showed us all how beautiful this game really can be. 


Thursday, June 20, 2019

Physical Therapist Board Certification

On a dreary morning in March 2019, shortly after we lost an hour for daylight savings and my internal clock was thrown for a disastrous loop like it does every half-year, I turned off my three alarm clocks which were completely unnecessary because I hadn't slept a wink, crawled out of bed, and drove over to a ProMetrics testing center near my house to complete the Sports Certified Specialist Physical Therapist exam.  I had my photo identification, my registration paperwork, and a list of test day reminders: make sure you remove all jewelry before going through the metal detector, be prepared to pull up your shirt and pants sleeves and have your ears checked, bring water and snacks because your exam is seven hours long but you can have a break in the middle, and a bathroom will be available.

Now, here we are almost the end of June 2019, more than four months later, and today I received the results - I passed my test!  I was walking out of basketball practice with the Storm when I glanced at my phone and saw the email with this report.  Without the Storm, I would not have met the criteria to even take this exam, because you need sideline coverage hours in a contact sport, and lots of them.  I'm so grateful for them.  Per the rules of the examination and ProMetrics, I won't go into any details on the actual content of this test, but I wanted to discuss the preparations I used and what advanced certification as a physical therapist even means.  Fortunately, I wrote many of these thoughts in March, because there's no way I would have remembered them now!  But I couldn't get myself to share it, in case I hadn't actually passed the test!

What does it mean to be a Board Certified Physical Therapist?  Right now, if you go to PT school in the USA, you're going to graduate as a DPT - Doctor of Physical Therapy - but you are a generalist.  You've learned the basics of physical therapy for all the areas of specialty that a physical therapist can work in and you took a big, terrible test that shows you are competent to practice physical therapy.  That test would cover all the different areas of practice and is very broad, covering a lot of topics.  After graduation, a new grad physical therapist will get a job and, with or without intention - begin to specialize.  To some extent, your job may dictate your specialty because that's the area of practice you're going to focus learning about moving forward.   The beauty of this is that you're able to change the area of specialty by working in different settings and pursuing alternative continuing education, but it also means that when we first come out of school - or if we change work settings - we're not very experienced in that care area early on.

When I first graduated, I worked at an adult orthopedic clinic while picking up shifts in a skilled nursing facility.  I focused my learning on orthopedics because it was my interest, but I had to learn the basics of the rehabilitation center because the needs of those patients were different.  Another example - if you came into the rehab gym at Seattle Children's where I work, you would see physical therapists working with children who have developmental conditions, which looks entirely different from what the sports physical therapists, like me are doing.  We're working side by side, all physical therapists, doing entirely different things from the same generalist education. I'm in awe of their work every day... and it's so different!

In some ways, the pathway of a physical therapist mirrors how a physician (MD) completes their schooling.  Any doctor you have seen - your primary care or specialist - went to medical school and graduated as a generalist.  However they can't practice medicine that way.  They are required to continue on their education pathway into a residency, determined by an intense matching program that I'm incredibly thankful I did not have to endure. They will be matched into the field they will pursue and specialize in, like emergency medicine, cardiology, orthopedics, family medicine... that list is super long.  And then, after another several years of working in their specialty while learning on the job, they become a specialized physician and can practice in their field.  But they don't have the wiggle room to wake up in the morning and say - I don't like being a heart doctor anymore, so I'm going to study diabetes and be a doctor for that.  They're a bit more restricted in their careers.

I have read articles recommending that physical therapy transition into the medical school model, requiring residencies to specialize.  This is an option now, but it is not required.  A physical therapist currently has the option to specialize in nine different areas, and this can be done by either completing a residency program and taking a big test, or by meeting a list of requirements and taking the same big test.  This is the test I took earlier this year and have been tortured into waiting four months to get my results. The residency program is meant to give you the hands-on experience and focused training needed to pass the test, but you're able to test without the residency and achieve the same end-goal if you meet specified criteria.

In early 2014 I had applied for residencies in Sports Physical Therapy.  I wanted to work in sports and having had years of experience working with women's basketball and a shortage of physical therapists working with the WNBA, I felt this was the direction I needed to go in.  At the time, I think there were fifteen programs, but only three had options that were not soccer (none had options specific to women's sports) - and those were the programs I decided to apply to.  (No offense soccer, but I'm a fair weather sports girl.  I'll support the USWNT all day long and cheer and attend games when the sun is shining, but a year of sideline coverage in the rain was NOT on my To-Do list.)  And so - I applied to University of Southern California, Ohio State University, and Duke University.  (It would have killed my Husky Heart to be a Blue Devil a little bit, though the education would have been superb at all three institutions).  Needless to say, I was not selected for one of the few slots available, a very sad failure, but a few months later I managed to secure a spot in the WNBA without it, so I took the alternative route. 

The options for physical therapist specialist certification right now are: Cardiovascular/Pulmonary, Clinical Electrophysiology, Geriatrics, Neurology, Oncology, Orthopaedics, Pediatrics, Sports, and Women's Health.  The list of accredited residency programs is here for all the specialties.  A recent presentation I watched discussed focus on making a new specialty for Pain, which has not yet been established, but that seems like an interesting approach to try to advance the use of physical therapists in treating people with persisting pain. Since I've previously written about pain on many occasions, and I work with the Seattle Children's Chronic Pain Team, I'm excited to see if that will be specialty number ten.

A little about preparing for the exam:

The application deadline for the Sports specialty was July 31, 2018 to test in March 2019.  These dates have been consistent annually with all the specialties having application deadlines sometime in July the previous year for a March test date.  That means that if you want to take the test in 2020, you have 1 month to apply - or even less! The application process is pretty complicated for some of the specialties if you haven't completed a residency, so I advise you check it out soon.  All the information you could ever need is right here.

So, once you've applied, the American Board of Physical Therapy Specialties (ABPTS) reviews your qualifications to determine if you're eligible to take the test in your requested area.  That takes about 6 weeks.  I started studying when I applied, but I know others waited to make sure they could even take their exam.  Here's a look at how I prepared.

First, I gathered a bunch of materials to help me determine what content I needed to study.

The materials I used were:
1) The SCS Prep Course from MedBridge Education which has a nice table of contents covering all the content areas on the exam.  They have prep programs specific to many of the specialty areas.
2) I googled "SCS Residency Program Curriculum" on Google.  There are many, but I used this one which outlined a lot of the content topics.
3) I purchased "PT Sports Questions" by Matthew P. Brancaleone PT, DPT, SCS AT, CSCS" a question/answer book off Amazon for $35.
4) I already have my CSCS (Certified Strength and Conditioning Specialist) and the book "Essentials of Strength Training and Conditioning" and the study guide I made when preparing for that test.
5) I borrowed "The Fundamentals of Athletic Training" book from my boss
6) I found my course materials from the Emergency Management Course I took at REI which was a required pre-requisite to take the exam.
7) I borrowed the Manual of Structural Kinesiology from the Seattle Children's Inter Library Loan System for a review of anatomy and biomechanics basics, particularly with regard to the mechanics of the shoulder, and review of throwing motions and gait cycle.  My test was two weeks before giving this presentation at Seattle Children's so I was preparing for both at the same time.
8) Per the recommendations of the curriculum in #2, I secured copies of the National Athletic Training Association Position Statements, all of which are free here as well as many of their consensus statements and several of the APTA Clinical Practice Guidelines here.  The highlight of reading those was seeing how many of my UConn mentors were authors of them, including Lindsay DiStefano, Doug Casa, and Robert Huggins.  Man UConn puts out some amazing stuff!
9) Lastly, and probably most importantly, the Description of Specialty Practice (DSP) for my exam.  The APTA has a breakdown for each exam listing the material that would be covered on it. If you're approved to take the test, they send it to you as part of your application fee.  Or you can buy it before you apply.

Second, I took a practice test.  Right from the start.  The MedBridge Prep Course offered several practice exams that were shorter in duration than the actual test and covered a wide variety of topics.  Based on the results of my first practice test, where some of my outcomes were abysmal, I knew how to prioritize things.

Third, with my current skills clearly identified, and more importantly, my biggest weaknesses, I looked at this ginormous pile of stuff to read and the ~80 hours of online MedBridge videos available, and, I made a study schedule.  This is the same approach I took when studying for the PT licensing exam, so I was optimistic it could be successful again. I tried to cluster things together in a sensible way.  For example, when I read the chapter in the Athletic Training book about weather-related injuries like heat stroke or how to deal with lightning, I also read the NATA position statements related to the chapter, and then watched the Medbridge Video on that same topic.While I was studying the weather-related injuries, two quotes stuck out to me that I had saved for this post  With regard to cold-related illness: "Nobody is dead until they are warm and dead."  So, if you find someone buried in the snow, they're not dead until their body has been warmed up.  And with regard to lightning injuries, "In the contest between people and lightning, lightning always wins." So I got the repetitions for a topics and kept notes on things that I was unfamiliar with or wanted to come back to after I had gone through everything once.  Repetition is helpful for me, but also sometimes felt like I was beating a dead horse by the end of some of the longer (or less interesting) topics.

And then I took my test.  I'll be honest - I was behind on my schedule pretty much from the second week, but I just kept plugging along.  I had an excellent student in the clinic, who I wrote about here and here, and who was treating about half of my case load for several weeks leading up to the test, allowing me more time to devote to reading papers and studying.  I read A LOT of the materials listed above, but found some of it to be too inapplicable to the patient care I typically do, that I decided it was worth leaving out some chapters despite the risk of doing so.  I watched almost every single Medbridge course that was listed in their prep program, several just listening while I was driving, including most of the optional ones.  I was stuck on the Brooklyn Bridge for over an hour in traffic and watched an entire course on nutrition in that time.  And I was certain that I did not pass.  Today's news that I passed was super exciting.  Hopefully writing up my preparations will help someone else on their road to board certification.



Thursday, June 13, 2019

Size Matters

This week I attended the quarterly Seattle Children's Hospital Sports Medicine Symposium on Upper Extremity Sports-Related Trauma.  I wrote about the inaugural symposium here which was about Mental Health.  I always enjoy these types of gatherings - a chance to network with providers I haven't had the chance to meet in the past and catch up with my colleagues who work at the other Seattle Children's locations, continuing education with my coworkers that gives us more things to discuss and new knowledge.  My clinic is not one of the surgical centers so it is a rare opportunity that I get to interact with the orthopedic surgeons whose patients I spend so much time with and there are other providers I just never get to see, so that was another positive of the day.

While there were many interesting things I learned at this week's presentations, one of the discussions closely overlapped with a current patient I'm seeing and a recent injury to a family member.  Dr. Thomas Jinguji and Physician's Assistant Leslie Rodriguez presented an entertaining and informative discussion on "Forearm, Wrist, and Hand Fractures" with considerations for returning athletes with these injuries back to their sports.  The forearm includes two bones: the radius and the ulna.  These bones are both commonly injured in "FOOSH" injuries - "Fall On OutStretched Hand."  I had a classmate in PT School who once answered an exam question that FOOSH meant "Fall on opposite shoulder."  I still find that hilarious.

XRAY of a wrist
The presenters discussed the differences in healing, treatment, and returning to sports between when the injury to the arm occurs close to the wrist (distal radius fracture) versus in the middle of the bone (radial mid-shaft fracture). In this XRAY, the top is where the radius and ulna join at the wrist.  Not shown is the rest of the radius and ulna where they would come to meet the humerus at the elbow.  There is a growth plate, called a physis at both ends of these long bones, which you can see.  These are open in children and close with aging.  The physes near the wrist, according to this publication, tend to close around age 17-19 with girls a bit earlier than boys.  At the elbow, the growth plates closer near puberty with girls around 14 and boys around 16, per this publication.  Injury directly to the physis can impact the growth of the bone.

Just beneath the growth plates you can see the metaphysis, where the bone is wider, and the diaphysis, where the bone is more narrow.  Bones are like long, thick pipes with a hole in the middle.  When a fracture occurs in the metaphysis, because this bone region is larger, the injuries tend to be more stable and the bone doesn't usually move as much.  These can often be treated using a cast for a few weeks.  Did you know that in many sports, you can play wearing a cast as long as it is covered with sufficient padding that stops it from acting like a weapon?  (Rules vary state by state, we learned about those for Washington at the symposium, too!) So these patients tend to have a period of immobilization, may or may not really need any rehabilitation at all, and tend to recover quickly - unless their initial injury was so bad that they needed to be put to sleep for a doctor to re-align broken bones.  The few of these I've seen in the clinic have really just been for a few visits where a kid was afraid to start using their arm, so it was a little stiff, but once they learn they're OK to get moving, they take a few visits to get back on track, work on squeezing some theraputty to get their grip strength back, and are often good to go.

The situation differs if the injury occurs in the diaphysis, the long shaft of a bone.  Because this is a narrower area, these injuries tend to be more unstable and displace more often.  This is where you might see a more gruesome XRAY and the arm looks wrong right away at the time of injury.  I guess in this case, size really does matter.  Injuries of the diaphysis frequently require surgery because these are unstable and need to be re-positioned and secured with hardware.  The surgeries may require plates and screws to align the broken bone, and then once healing has progressed sufficiently, they will have another surgery to remove the hardware.  Two surgeries!  As you can imagine, this means slower recovery, longer period of immobilization, and greater need for rehab.  I've seen more of these in the clinic than the other type, though mostly I see elbow and upper arm injuries much more than at the forearm and wrist.

After learning about the differences between these two locations and the bone diameter/size and why that matters, I sent the presenters an email asking if this same concept applies in other long bones of the body.  I'm currently treating a patient recovering from a broken humerus and my nephew broke his in February, both from skiing accidents.  While the principles of the bone diameter are similar and the metaphysis is larger than the diaphysis, Dr. Jinguji was kind enough to educate me that it turns out that you can't just apply this same principle of recovery across the board. At the elbow, you need to have more consideration for the joint as well as the bones and so the metaphysis at the elbow is often as unstable and challenging to deal with as the diaphysis.  The proximal humerus (near the shoulder) behaves a lot like the distal radius (metaphysis injury described above), where it's proximity to the body and its size are probably helping those fractures to be more stable.



My nephew, Jeremy, broke his distal humerus in February.  With his permission to share, here's what it looked like when he injured it and a picture of the pins the surgeon put in to hold it together after everything was re-aligned.  They put those pins in, and actually left the ends of the pins out of his skin so he didn't need as much of an intense procedure for them to remove them after the bone had healed.  The pins were covered up by the cast and he was immobilized and in a sling for four weeks and then the pins came out and he was immobilized a little longer without the hardware before being cleared from everything.  He didn't need any physical therapy, despite my begging to get him some rehab to restore his motion.  Three months out he tells me he's pretty much back to his usual teenage boy things.  That cast certainly didn't get in the way of his video gaming skills.

Overall the presentations were really great and I enjoyed learning some new things and can't wait to hear what the topic of the next symposium will be.  The only negative of these events is the super early start time getting into Seattle... definitely interferes with my sleep!