National Eating Disorders Awareness Week

The majority of this post was originally written in August 2018 and has been sitting in limbo, mostly unchanged since that time.  There were too many excuses not to post it... but it's time.  Because someone else may benefit.  Someone else may learn they're not alone with what they're going through.  Someone else may need a place to look for help.  And I have nothing to be ashamed of.  I have nothing to lose.  And it's National Eating Disorders Awareness Week.  And I'm home in Connecticut with my family right now.  And I've run out of excuses not to post it. And because of the treatment I've been going through, none of my pants fit.  So... let's have some awareness about Eating Disorders, RIGHT NOW, and then take a moment to love ourselves. Come as you are.

Maybe I'm wrong, but as an East Coaster, I feel like there is a stigma against seeing a therapist. Not a physical therapist like me... we're totally cool on both coasts... a mental health therapist...a psychiatrist or psychologist... a shrink.  The vibe just isn't the same from coast to coast. The only people in Connecticut who ever mention seeing a therapist (to me) were working through marital issues or recently had a significant trauma, and even then it was a hush-hush conversation. I still can't identify a single friend seeing a therapist at home. That doesn't mean it isn't happening, we're just not talking about it.  I can easily identify several friends who have experienced things they probably should see a therapist for... but after my own experiences, I realize that it only works if you're ready to face your own issues.

Things in Seattle are different.  Not only is therapy a common activity, but people talk about it freely!  I'd text a friend asking to grab dinner and they'd say, can we go at 7PM after my therapy appointment?  And then we'd meet up and sometimes discuss what happened at their session: new revelations, techniques to try this week, weird questions they were asked that were surprisingly thought provoking. It's amazing how removing the stigma makes it comfortable and so much less of a big deal.  Pretty much all of my favorite people in Seattle have seen a therapist at some time - and none have been shy with talking about their experiences.  

If you know me beyond this blog, you know I'm 100% extrovert.  At best, I tolerate solitude. I thrive on social interactions.  I'm jealous of friends who say they need alone time to recharge their batteries because I just don't operate that way.  I talk to people all day long at work and then want to keep being around other people because it's like a constant energy flow... or a way to avoid whatever is going on inside my own head.  So when I first moved to Seattle and didn't know anybody, I spent several months, night after night, and all my days off, alone without anyone to talk to over dinner or to go for a walk with and sit and watch TV together.  I was alone.  I was missing my family and friends who were insanely hard to reach due to the time difference and my work schedule.  All that time alone could have been an opportunity to learn about myself or find some hobbies, but what I learned was that I couldn't tolerate being alone, and instead turned to food for comfort.

Interesting how moving 3,000 miles across the country doesn't make binge eating go away. I didn't know before moving that I fit the criteria for an eating disorder diagnosis... I just thought I had poor self control.  I was living alone after spending three years with two amazing roommates who had delicious snacks around the house.  I stole their food and would replace it without their knowing... only to steal it again later on.  One time, one of them had taken a single bite out of a Snicker's bar and put the rest into the kitchen cupboard for later... I finished it, drove to 7-11, bought another one, took a bite out of the new one, and put it back in the spot I had taken it from.  I did it 3 nights in a row, finishing the partially started one and replacing it later on... she never knew.  When I told her about it, we laughed.  Then I cried.  Then I asked if she had half of a candy bar around for us to share.  Neither of them knew the kinds of things I did eating their food. I'm that good at hiding it.  So when I moved, I figured if I didn't buy the snacks and they weren't in my house, the problem would just go away. I was wrong.

It took almost a month for all of my stuff to arrive in Seattle from Connecticut.  I slept on a blow up mattress in an apartment with no furniture, enough clothing for one week, no dishes, eating rotisserie chicken with plastic cutlery standing over the kitchen sink.  I borrowed the money to move, so I didn't have much to spend.... but then I would find myself in Dollar Tree searching for cheap binge foods.  Trigger alert: Did you know they sell whole bags of mini Mr. Goodbars? And pints of ice cream?  And weird brands of chips?  And actual M&M's? Each for a dollar?!  I still cant make it out of the dollar store without buying foods I used to binge on... but now I can manage to only buy one instead of before where I would have bought a lot more.

I knew I did this for years in Connecticut... but it took me far too long to realize how much of a problem I was experiencing. I didn't know that it wasn't normal.  Other people don't buy a whole box of Cheez-Its and eat them in their car and then throw away the box so nobody knows it happened?  Nobody else walks to 7-11 with a spoon in their pocket so they can eat the whole pint of Ben and Jerry's and it never even enters the house?  Nobody else sees a coworker bring in a box of donuts and politely declines them all day long only to have the last three at the end of the day when the office has left and you've stuck around until the coast was clear? Anybody else feel like they've blacked out while they're eating only to realize the box of whatever you're eating is now empty... and not remember eating past the third bite?  Just me?  I was in the dark for a long time about what's going on in my head and what I've been doing to my own body.  Not any more.  It isn't just me.  

So I was alone in Seattle, no local friends, living alone, and starting a brand new career in a city I didn't know.  I'm working with a lot of youth athletes as well as with professional women's basketball players who are incredibly fit, strong, powerful, beautiful, and intelligent. I'm working in my dream job in the WNBA while morbidly obese.  How can I possibly survive this career promoting health, fitness, and exercise while I look like I do?  Who would choose a fat healthcare provider when they could have a fit one who looked like a healthy person?  I convinced myself on multiple occasions that any job I was not hired for that I applied to was because of how I looked.  Not because I'm a bit loud in personality.  Not because I was a new grad physical therapist.  I was certain it was because I was fat.  I tried to lose weight for the zillionth time in my life doing the Whole 30... but when I would reintroduce foods back into my diet, not only did I gain back the weight I had lost, but the binges got bad. Really bad. I go through cycles.  Out-of-control eating followed by a strict restrictive diet for a few months, lose weight, feel good about myself, and forget there's anything wrong only to lighten up a little on my eating restrictions and have it blow up in my face.  I'm not sure if anyone knew about my bingeing... certainly nobody confronted me or offered help.  I don't remember ever being caught.  I did it in private.  Correction: I do it in private.

I really wanted to fix this problem on my own, without ever discussing it or telling anyone else.  I was ashamed.  I'm still ashamed.  Though I'm starting to learn that there's no reason to be ashamed.  The Whole 30 was my last attempt at trying to go it alone before seeking help.  I didn't know what I was looking for.  For years I had told myself that I just needed to learn self control... restrict eating sugar, go on yo-yo diet episodes.  My best friend told me in college that I was happiest when I was on a strict diet. (She also told me I could make friends with a squirrel... isn't she the greatest?!)  But she's right.  Somehow, when I diet, I don't binge... until I stop the diet, and the binges take over. So I started googling online tests like "How do I know if I have an Eating Disorder."  I took about 7 of them.  (Here's one you can try if you're questioning this for yourself). They all said I did.  Every test said to get help.  They all recommended treatment. And then the creepy Facebook ads that read your mind started recommending the Emily Program.

So in February 2015, six months into living in Seattle, finally having made a few friends who all loved their therapists, I went to the Emily Program, a facility that evaluates and treats people with eating disorders.  They, too, have an online quiz you can take to see if you might need treatment on their homepage.  My intake paperwork took over an hour to complete with boatloads of tests asking me questions about eating habits, body image perspective, weighing myself, tracking my food, exercise routines... it was extensive and thorough.  I cried the whole time.  Not just tears streaming down my face... actual sobbing. I was so thankful I was in a room, alone, at a desk that was facing the wall.  I remember thinking... how does this place not have tissues? And why did this take me so long?  Not the paperwork... getting myself into an office where I could get some help.  

The intake specialist whose name I don't recall and whose face I could not pick out of a line-up diagnosed me with binge eating disorder that day. (Click the link and read about it.  This is National Eating Disorders Awareness Week, after all!). She told me I was not testing to extremes which meant I was unlikely to hurt myself beyond the damage of excessive caloric intake in short periods of time, and recommended some counseling.  I didn't need hospitalization or medication but was given a phone number to call in case I started considering self harm. So I set up some appointments with a therapist.... you know... one of those people we East Coasters despise...And I went.  And there was a couch in the room but I didn't lie down on it.  And I hated it.  Despised it. So I stopped going. 

I told my family.  I told a few friends. A few Seattle friends were recommending their therapists to try - maybe it had just been a bad fit.  But I was dead set against therapy and refused to do anything more than I had already done. Now I had an excuse.  I'd binge and then say - well, I have an eating disorder, so this is just going to happen. Then I'd do another round of the Whole 30 and lose the weight.

That was my cycle for the past three years.  A Whole 30, I'd feel amazing and lose weight, and then I'd have binge rages.  Despite the definition of insanity being "trying the same thing with expectations for different outcomes," I kept doing the Whole 30 because it made the binges stop, even if just for a month.  And I felt really, really good while I was restricting my diet.  I also read a book on mindfulness, a few about nutrition.  I tried the HeadSpace app for meditation... that one I really despised.  I started doing yoga - which I wrote about here - and which was the only thing I tried that I actually enjoyed and helped me channel my energy in a new way, but it wasn't changing my eating. 

All this to lead up to the fact that I had my annual physical in 2018 and my primary care doctor flat out told me to go see another therapist. For a lot of reasons.  She told me that I shouldn't feel like I needed to figure it all out on my own. And that's where this blog post came to be.  I'm sitting in the waiting area for my intake session with my new therapist, freaking out, and for some reason, I started writing what was going on around me to distract me from the fact that this couldn't possibly go well.

I had to fill out paperwork asking me questions about how frequently I'm sad or anxious or can't get out of bed or don't feel joy the way I think other people do, and what brought me to treatment and, as is typical for me, I was way too early, so I got stuck sitting in the waiting room feeling like I was running down a hallway naked. I'm holding a book on my lap but I can't possibly read it.  I'm wondering ALL THE THINGS. Can you talk to others in the waiting room of a therapist's office? (I wouldn't at the dentist... why would I think of that here?) I need to go to the bathroom, but don’t know where it is, and the lady that's also sitting here seems comfortable here, unlike myself.  I need to go before my session... oh she smiled at me I guess it’s OK to maybe ask. Thank you, kind stranger also working on your mental health for pointing to a door.  Walking around aimlessly didn't seem like the right approach...

Back from the bathroom... are there any men here? I've been here 20 minutes and have only seen a few women.  Otherwise this place is too quiet and there aren't enough pictures on the walls.  Why is the music playing so loudly?  How was my previous sentence that the room is too quiet while also feeling like the music is too loud?  Awesome, they have coffee... oh wait, I don't drink coffee.  Oh... the other side has tea.  And that lady just stole 2 tea bags and put them in her coat pocket!  Seriously? Maybe one of the therapists here treats kleptomaniacs... should I admit that I'm a pen stealer?  Yes! A man! Oh, he works here. Figures.  Men never have problems.  Wow my sarcasm level is elevated sitting here.  I'm starting to sweat.

Checked the time on my phone. She's running late. I never run late. I already said that. I also don’t generally feel like I’m a nervous person.  When was the last time I was nervous?  Oh yeah - that was when when I had my work annual review.  My boss is my favorite person on the planet for 364 days of the year and 365 on a leap year... but then all of a sudden she’s a Dementor because we have to discuss my performance. I normally wear scrubs and a light shirt to work, but for that first review I chose to wear khakis and a long sleeve work jacket because I'm getting reviewed and maybe I should look a little bit professional... And then I was sweating and my heart was racing.  Yep... I can remember exactly one occasion where I was considerably nervous in the past year... until right this second.  I'm not sure which is worse.  Actually, that's not true.  I'd rather be sitting with my boss.  She already knows I'm crazy... this therapist does not yet know.

And then she brought me into her office. Of course she would also be thin and gorgeous...how can she possibly know anything about being fat? That's not going to make this easy.  I can't possibly like this therapist woman who looks like she's the same age as me and if we met at the bar, we'd probably get along just great. With my own new patients, I start with "What brings you into Physical Therapy today?" and then follow with "Have you ever had physical therapy before?" which, if they have, I ask, "how did it go - what worked and what didn't work for you?"  I didn't even give this therapist a chance to ask her usual questions, I just blurted out the answers to those from the very start in a stream of consciousness - kind of like this blog post has come pouring out of me:

"I come from a place where there is a stigma against therapy and that makes it hard for me to buy into this process. I know the impact of buy-in on outcomes and am willing to try to overcome this barrier. I never connected with my previous therapist because she was constantly saying 'I'm curious about...' and I would count how many times she said 'curious' in each session which was insanely distracting. I really need you to be receptive to what I'm saying until we get comfortable with one another and I need you to not be curious.  I know that if this relationship doesn't work out, there's no chance I would try this again with a third therapist, so basically you're my last hope. I don't want to do this... but I need to do this." Yes I sounded that desperate.  No I didn't cry.  She asked me to commit to six sessions and that we would re-assess then.  I'm certain now that she's the second best decision I've made living in Seattle... the first was working at Seattle Children's, which I celebrated two years at yesterday.  Thank goodness they somehow didn't notice that they were hiring a fat physical therapist... or if they did, it wasn't a barrier for them.  They do list Diversity and Inclusion as one of their workforce values... I'm not sure if obesity fits into that, but I'm happy to make the office photo look a little bit different.  To be honest, with some of the kids we see, it may be the best thing for them.

So now I'm telling all of you.... many months later.  Because making excuses means I can't move on. Because if I say it isn't that big of a deal that I see a therapist or that I have an eating disorder... then it can stop being such a big deal. Because I work with kids, particularly teenagers, and I sometimes suspect that they're experiencing similar issues to what I'm experiencing and they don't know what to do... so here's one more piece of noise on the internet that maybe they'll come across and ask someone for help.  Because I have a teenage niece and nephew who are surrounded by the pressures of middle school who I hope will grow to love themselves and be able to express themselves better than I am able to.  Because when I tell my therapist that something she's doing is bothering me - she stops doing it.  Just like I do with my own patients. And because of this, I now trust her.  Because I've been working on improving my "situation" - which is, I'm told, a disease - even though, until I knew I had it, I don't know that I realized how sick I really felt.  But truly, a lot of the time, I actually feel quite sick.

I'm learning a lot about myself and can see things changing, particularly my mood, which has actually gotten considerably calmer without so many extreme sugar-insulin spikes - but other things as well. Things got a lot worse before they got better.  They might get worse again... never know what that sneaky therapist might uncover. I haven't been on a diet in eight months.  Before that, the longest I think I've gone was three months without dieting for the past 20 years. I am out of my comfort zone.  No diet = weight gain = a lot of inner struggle.  I want to be on a diet.  I want to be off sugar.  I want my pants to fit. But I'm learning that I can't do that because in the end, it makes things worse.  So I'm going to try trusting the process and realizing that I have a crew of people lined up to help me now... there's a dietitian in the mix... is there a stigma against that, too?  And so what if my old pants don't fit... I can just buy some new ones.  Or wear scrubs.  They have an elastic waist band.

Come as you are.

Do No Harm.

This week on the social media interwebs, I saw a startling video of a rehab session of WNBA Player Angel McCoughtry. Angel is a two-time Olympic Gold Medalist and five-time WNBA All-Star who plays for the Atlanta Dream. She's a star on the basketball court.   The first time I saw her play in person was when her Louisville Cardinals lost to UConn in the 2009 NCAA Women's Basketball Championship in St. Louis but I've easily been watching her play since 2005 when Louisville entered the Big East Conference... she's a really fun player to watch, very dynamic and energetic.  I saw Kevin Garnett play in Boston for the first time after I had seen Angel play and thought he reminded me of her.  Unfortunately, Angel hurt her knee towards the end of this past WNBA Season and required surgery - information she posted on her social media pages.

Last week, Angel posted this video of her recent rehab session on her twitter and instagram accounts:

It’s easy to see the glits and glam of success , but this is what it looks like behind closed doors! pic.twitter.com/dtjy28QRmU

— Angel McCoughtry (@angel_35) February 14, 2019

I'm speechless watching this. It takes a lot to make me speechless... but this did the trick.

I'm not treating Angel's knee condition so I don't know what she's gone through to this point - or what the goal of this particular moment is - but I can make some educated guesses based on my work as a physical therapist and with women's basketball players.

Trying to bend a joint past what it is able to do is incredibly painful. The mobility is necessary, so it's possible that this rehab team has tried numerous other options before using this technique to try to get her knee to bend sufficiently. I'd have no way of knowing, but I do know that even if I had tried everything I could think of - this would not be in my list of treatment options.

There are many studies that show the need to have symmetrical knee mobility (both sides bend and straighten the same amount) to have normal walking pattern which would translate to normal running pattern.  However, this paper also examined the number of post-op ACL patients who don't get back their full mobility and found it to be 11% in a sample of 244 patients. This paper discusses the way that scar tissue build-up in a knee is classified and what is generally done if physical therapy intervention is insufficient.  Asymmetrical mobility increases risk of injury - and nobody wants that.  While I agree that she should have matching mobility on both knees, the method being used to achieve this seems inappropriate.  I have never done this in over four years as a physical therapist and, when I saw the video, I distributed it to several other physical therapists and athletic trainers, all of which agreed that there are numerous better ways to achieve the goal they're trying to achieve in the video.

It looks like someone is trying to make Angel's knee bend more than it currently does.  Knee flexion (bending) is a challenging thing to achieve sometimes, particularly after surgery, and sometimes it even requires an additional surgical treatment called a manipulation under anesthesia, in which a person is medicated so that they won't feel it when their knee is forcefully bent all the way to restore full motion.  These can be incredibly painful procedures and with the WNBA season starting in just about two months, nobody would want her to have another surgery when she;s starting to get back onto the basketball court to prepare for the season.

This research article from 2008 uses a similar position to try to get knee flexion but describes the need to hold the position for extended periods of time - at least 10 minutes - and notes that having a physical therapist apply this type of sustained hold is incredibly fatiguing to the therapist so it recommends using belts on a table to achieve long duration, low load stretching.  However, it also specifically states that the hold should be to the tolerance of the patient and may be a little uncomfortable.  I would argue that the session in this video is not to the patient's tolerance and is therefore harmful.

These papers: 1, 2, 3, 4, 5, are just a few which suggest alternative ways to achieve the same goal - or the last one talks about the lack of evidence to support what's going on in the video. A brief summary of each:
1) An alternative technique to use to try to gain knee flexion range of motion
2) Another alternative technique to use to try to gain knee range of motion
3) A list of manual therapy options with photos from a University of Kentucky physical therapist - none of which are what is used in this video.
4) This is from the PhysioPedia which includes videos that even include knee flexion in the prone (face down) position like the one in Angel's video, however you will notice joint mobilization is being used rather than just a cranking technique, and, if your sound is on, you will also notice an absence of apparent pain.
5) This is a much older paper from 1992 that looks at ways to change the length of connective tissue (like the ACL or capsule around the knee joint) which is composed primarily of collagen.  It describes that there is not sufficient understanding of how much force would need to be applied to make change in length of these tissues - but that if that force were measureable, it would require some amount of damage to the tissue.

So, if you're receiving physical therapy treatment and you're experiencing pain during the session that feels like it is harmful to you, tell your provider to STOP.  Sometimes treatment may be uncomfortable - and that's ok - but if you're yelling out, that's not ok.  You should ALWAYS feel like the treatments you are receiving are helpful.  You should ALWAYS know that you have the say of what is being done to your body.  And you should know that you ALWAYS have the right to ask why something is being done to you - and if there is another way it can be done.  Because in this case, I strongly believe there are alternative ways that are safer, more effective, and that do not look like torture.  Physical therapy gets a bad reputation because the abbreviation, PT, also is jokingly referred to as Pain and Torture.  This is wrong.  And if you feel like your PT session is more like pain and torture, please get another physical therapist.  We take an oath to Do No Harm.  The Hippocratic Oath of healthcare providers.  We should be living up to our oath.

Wishing a very speedy recovery to Angel McCoughtry.  I can't wait to see her back on the basketball court. And I hope her rehab is not painful in the future.

Conflicted

Hey everyone.  This past week I've been conflicted with something I use in my patient care.  Conflicted enough that I've brought up this conversation with my coworkers and a close PT friend and it's still weighing heavily on my mind. So now it's here for others to read and comment on. Please send your thoughts, fellow PTs.

There is a physiotherapist out of the UK named Adam Meakins who posts regularly about various physical therapy topics including issues with the profession, our techniques, and our shortcomings. He goes by "The Sports Physio" and has a very respectable social media following: 54.4K twitter followers and 76,000 followers on his blog... compared to my 270 twitter followers and 9 blog followers (plus my mom).  I present these numbers for the sole purpose of demonstrating that he's a well-known PT.  I have followed him and read his materials for about a year and have come to find that he challenges my thought processes, which is essential for my growth, though sometimes is hard to swallow.

ID 2530204

© Chrisharvey

| Dreamstime.com

In the past week, two physical therapists who I respect - but also occasionally differ in opinion with - have mentioned Adam Meakins. One of them linked to a video Adam posted on Facebook which he further discussed in this recent blog post and he was also interviewed on this podcast about a different subject - so he's just come up a lot more this week than usual and his messages have been on my mind.

This post is not meant to be an attack on Adam.  He works hard to improve healthcare and physical therapy practices - noble efforts with messages I often agree with.  He expresses his perspectives confidently in an unapologetic abrasive manner that has a certain appeal for getting his message across.  (AKA - there's no bullshit.  He tells it like he sees it.  I love this about him.) He's a physio and he's trying to help people live healthier lives doing the things they love to do... so I respect him. I have never met him in person (yet), but I do pay attention to what he's posting because I think his perspective is really valuable, even if mine differs, like it does right now.  I wonder what it would be like to shadow him treating patients for a day.

The blog (and video) he posted discuss the use of palpation (evaluative touch) and how we present our findings to patients.  

Adam listed multiple studies as his references, many of which I have now read, which report that either more research is needed or that palpation techniques are not reliable. To my knowledge, there are not many papers that say the opposite, and my skills of critically appraising research are certainly inferior to Adam's, but this paper contradicts the research presented in Adam's blog post.  I had to search to find that one.  I searched because I have found multiple occasions where someone has told me to do something with patients because they read an article about it - and I was able to find multiple publications that stated the opposite information.  So when I read his post and immediately felt like it didn't sit right with me, I had to do some searching. Maybe I don't understand his message properly.  Maybe I'm too biased to see through my own thought processes.  Regardless, I am conflicted.

Adam points out that physical therapists are not good at palpating things like "knots" or "trigger points" or "tight bands" or "joint play at the spine" and that we are not consistent between providers or even consistent with our own practices.  In non-medical terms - if you smell pizza in the morning and identify that it is, in fact, pizza - but in the afternoon smell the same exact thing and identify it as a cheeseburger, you're not being consistent with your own findings.  And to tell someone that you have a cheeseburger when it's actually a pizza could be confusing or problematic.  Scientific research says that physical therapists touch patients to evaluate them but report different findings. The research also says that we cannot identify if parts of the spine moves abnormally or identify which level of the spine we're touching with consistent results.

Now... when I palpate a patient and feel like a segment of their lumbar spine feels hypomobile, I agree with Adam that it makes no sense for me to state the specific level of the spine to the patient, because I don't have XRAY vision to know I'm 100% accurate and, working with kids, it probably doesn't have much meaning to them anyways.  I worked with a patient with neck pain today and, as I've previously mentioned, I currently have a student.  So when I palpated a segment that I thought was hypomobile (and reproduced the patient's symptoms), I relayed to my student that she should look around where C3 would likely be because I can't actually be certain that it is C3.  I think it is, I'll document it as such, but the reality is - I don't actually care exactly what level it is.  I feel something, it reproduces my patient's symptoms, it's where I want to treat.  I don't know how I could have better directed my student to what I found for her to feel it herself, but the patient felt relief with mobilizations at this region.  Adam's post suggests that this confirms my bias to this being a useful technique.

Maybe it's more about the way the care is interpreted and explained to the patient than the actual identification of specific structures and the interventions that are applied that Adam has a problem with.  I agree with him that we really need to STOP TELLING PEOPLE their L5 is rotated or their back is out. What does it mean for you to throw your back out?  That is not medical terminology.  Can your back ever be in?

But... when I palpate, particularly at the spine, I do feel "something." Of course I'm biased on my opinion of my own patient care...it would be wrong of me to use interventions that I did not believe were helpful and, since I also manipulate the spine on occasion, I feel it is essential for me to use palpation to identify hypomobile segments of the spine.  I feel hypomobility in some regions compared to other regions in the same person.  While I don't generally compare spinal mobility person to person because I don't find that useful, I do correlate certain patient responses with what I'm feeling in soft tissues in my hands and compare that to what I've felt with others.  If a person laying on the table in front of me presents with a neck that is tender to palpation and their cervical and thoracic spine feel stiff compared to their lumbar spine, I want to treat this issue.  Maybe with manual therapy.  Maybe with exercise.  Maybe with both.

I used to do things very differently.  I no longer say to my patients, "Wow your neck is really stiff," or "Your 1st rib is stuck"- though I do sometimes feel a stiff neck and a hypomobile first rib... which I treat.  I don't say these things any more because it freaked out the patients.  They'd worry about their rib being a problem.

I used to look at the pelvis and tell patients that they had one leg longer than the other. All the time.  Guilty. I didn't know better, then! I used long axis distraction of a leg to distract the hip while simultaneously re-aligning the SI Joint.  That's what I truly believed.  I'm telling you that I used to regularly yank on people's legs. Maybe as often as daily. Wanna know why I did it so much?  Because sometimes IT ACTUALLY WORKED.  And they felt better.  And that's a bit of what Adam Meakins is saying... that we can be convinced that the care we're providing is beneficial, even when it is not supported by research. I eventually learned that it didn't work as much as I thought it did.  It didn't help enough people.  It could have been harmful to the patients and I constantly felt like I was doing something to patients to try to fix them rather than guiding them towards ways to fix themselves.

Humans can't be symmetrical if we have hand dominance and we move to get in and out of a car in the same way all the time but less frequently on the other side of the car. Our heart is not centered in our chest cavity.  There is only one spleen and one liver and they're not in the middle perfectly symmetrical....  So while Adam Meakins is practically pleading with physical therapists (and hopefully chiropractors and physicians) to STOP telling our patients that they have anatomical problems that are probably not actually problems, and I agree with that message... I still feel "something" when I palpate the spine.

If patients ask, I now use an explanation about the nervous system having a reason to try to protect that particular region of the body and that by using load management strategies, it may calm down. I explain that "hurt does not equal harm"... that the tissues of the body may hurt even though damage is not occurring.  The body uses pain to protect itself.  And then I give a home exercise program to guide them on restoring motion, strength, or function based on what I determine the patient needs... which I did by using palpation.

I remember sitting in PT school and being taught how to palpate the multifius and the transverse abdominus musculature to assess if they're contracting.  I could never feel the multifidi.  Never.  And then the PTs at my first job out of PT school encouraged me to focus on assessing the multifidi in various positions and using abdominal bracing and using electric stimulation in conjunction with abdominal bracing on my patients.  I tried to use that.  But I could not feel it.  This is what Adam seems to be describing but relevant to palpating the spine.  Is it possible that we have different skills with regard to palpation?  Is it possible that while I cannot feel the multifidi, I could feel hypomobility at the spine?  Is it possible that the issue is not about what we identify, but more in how we express it to our patients?  We are definitely impacting the beliefs of the patients we see.

The podcast interview goes a bit more into the discussion of the narratives that physical therapists (and healthcare providers) present to their patients and how this can negatively impact them.  I like that Adam states in the podcast that removal of pain is the wrong way for PT to be going as a profession.  We need to be empowering patients, give them realistic expectations, and help them operate within the constraints that their individual bodies allow.  The goal should be developing resilience and tolerance - not elimination of pain.  I agree with Adam on all these points.

I also agree that we are over-treating patients.  Too many visits.  Too many referrals from person to person rather than really understanding what's going on.
I also agree that the medical system doesn't operate in an ideal fashion.  Insurance companies limiting treatment influence the care that patients get.  This is wrong.
I also agree that sometimes the best treatment for a patient is NO TREATMENT.  I recently was working with a patient who was seeing so many different providers that I just sat her down and told her - I think you're trying to find too many solutions to a small number of problems and can't follow a single path to your recovery.  I recommended that she sit down and write a list of all the people she had been seeking answers from, and pick the one that she wanted to commit to.  Who do you believe is helping you?  Follow that person.  Get rid of the rest of us.  Everyone telling you different things is confusing and ineffective.   I don't actually care if physical therapy is her solution.  The best solution for every patient is the one they buy into and helps them find a way to get back to their function.  Period.

Even as I write this, I'm feeling my thought processes shift about what I say, but I"m not ready to throw away palpation yet.  I like that I'm trained to provide spine manipulations and have had some really great results using it. I use it selectively and in conjunction with movement.  And so, I'm unwilling to throw away a tool from my toolbox that I sometimes find essential.  At least for now.

Take Home Message: There are lots of really good physical therapists out there, many of which are creating content that is easily accessible and easy to apply.  The messages differ between them.  But patient populations differ and you have to believe in what you're selling to your patients.  I believe in a little Mike Reinold and a little Lenny Macrina and a little Lorimer Moseley and a little Adam Meakins and then I add some strength and conditioning with Eric Cressey and a little breathing from yoga practices and a little mental health... and I'm my own unique clinical provider because of all those influences... which is why I keep writing about all of them!  So use a variety of backgrounds and consider opposing opinions, try out different techniques, challenge your own beliefs and welcome growth along with failure.  Feel free to tell me if I'm wrong... I may not like that, but I'd like to think I'll be respectful and consider the alternatives.

Above all else - Do No Harm.

Basketball Bucket List

Sometimes I write about basketball.  This is one of those times.

Do you ever write a list of things to do for the day, and then when you realize you've completed something that wasn't on the list, so you add it on to feel like you've achieved more tasks?

I have a bucket list....places I'd love to go, people I hope to meet, events I'd like to attend, even some personal accomplishments I'm striving to achieve.  I started the list the day after I met Michael Jordan because I realized that meeting Michael Jordan would have been on a list if I already had one.  Like when I go about my day running errands and then realize I did my laundry but it had never been on the list!  I wrote the list in 2009, but added things on there I had already accomplished, because they would have definitely been on my bucket list if I had written it sooner.

Michael Jordan

Michael Jordan played in the NBA from 1984 (the year I was born) until 1993, then again from 1995-1998, and then from 2001-2003 (the year I graduated from High School).  I started watching UConn Women's Basketball in the 1990's and definitely was not watching the NBA while MJ was playing.

Sometimes events transpire that make it impossible for me to check off an item on my bucket list.  For example - I never had the opportunity to meet Pat Summitt, legendary women's basketball coach at the University of Tennessee.  When I was in college, I disliked her for what she represented and for the rivalry between our teams, but as a fan of women's basketball, I now appreciate that she made significant contributions to women's basketball that have allowed me to experience many incredible opportunities.  Knowing I'll never meet her is a big disappointment.  Watching Michael Jordan play NBA basketball is another thing I'll never achieve. Bucket list failures. Never to be checked off the list.

I don't want this to happen with other trailblazers and superstars in the basketball world.  I want to meet so many people and watch many others play in person. My first NBA game was in Boston and I remember seeing Ray Allen and Kevin Garnett and Paul Pierce plaing together and dunking.  Kevin Garnett had always been portrayed like a bit of an animal - and his energy came across even bigger than that at the Boston Garden. They were SO big. SO athletic. SO much higher up in the air. And, in the moments when they made an amazing play, the world seemed to slow down for a few seconds.  But those were just moments.

It was on my bucket list to watch Kobe Bryant play.  I bought tickets to the Lakers @ Nuggets game while I was on clinical rotation in Denver on March 7, 2014.  He did not arrive with the team and was announced to be out for the rest of the season with a knee injury. I'm pretty sure he had a tibial plateau fracture.  It made me really sad to miss that opportunity because, just like taking a photo of the mountains - the scale is changed when you look at things through a screen.  I needed to see him in person.  He retired from basketball and I'll never get to see it.

This past weekend, I headed to Oakland, CA for the Golden State Warriors versus the Los Angeles Lakers.  If I couldn't see Kobe, at least I could see LeBron James in action. He's the greatest of my time.  But LeBron didn't play this past weekend. Bucket list fail. Again.

LeBron was taking the night off for "load management."  The Storm Strength and Conditioning Coach who was with me for the game said to me, "Well, LeBron's old, so that might start happening a lot more, now."  Excuse me, WE are not old!  His glory days are not yet over.  I'm not crossing it off my bucket list yet because it can still happen, but I feel like I've had three basketball bucket list fails. I was disappointed that I missed a chance to see one of the greatest men's basketball players of all time playing live, but I loved the reason they used.  As a phyical therapist, all I really do is load management.

My favorite thing about LeBron James, beyond the fact that he's an amazing basketball player, is that his birthdate is December 30, 1984.  Two days after my own. So, really, the only differences between me and LeBron James are two days and a few dollars.  Nothing else. Ha!

It hurts too much when you run, but you can tolerate walking?  There's a load you can manage.  A ten pound bicep curl hurts but five pounds doesn't?  We've identified a load you can use.  "Shin splints" from ramping up your training volume too quickly for a marathon?  Improper load management could be to blame. If you had to define what physical therapists do in two words, I think it would be appropriate to say, we "manage load."

So... while I'm bummed that LeBron didn't play, and I don't know that I'll ever get the chance to see him again, I'm glad to know that the Lakers are at least using terminology that makes sense from a rehabilitation perspective. 

Enough of the bucket list fails. I've also had bucket list successes.  The basketball bucket list includes a ton of women's basketball opportunities and must-see/must-meet experiences, and that's where my heart truly lies.  Also, this week (February 6, 2019) was National Girls and Women in Sports Day.  This is a special day that gives a chance to pay tribute to the women in sports who have helped paved the road to allow for more opportunities for girls and women in sports today.  I've previously written posts here and here about women in sports and am so grateful to those who have paved the way.

Attending a UConn National Championship win in person would also have been on my bucket list, except I wrote the list after having that chance.  My freshman year of college, the team won, but I wasn't traveling with the team.  I had attended the National Championship in 2006 when the University of Maryland - with current Seattle Storm power forward Crystal Langhorne - beat Duke University in Boston. It was incredibly fun, especially because I've always loved the Maryland Terrapins and was so close to going there myself - but it wasn't my team.  So when a group of us were able to attend the 2009 National Championship in St. Louis, MO when UConn beat Louisville, it checked off a box on my future list.

The NBA has been around much longer than the WNBA, so where I didn't have the chance to see the pioneers of the NBA, it's an entirely different story for the WNBA. I saw Rebecca Lobo play live basketball. And Lisa Leslie.  And Tina Thompson.  And Katie Smith.  And Sheryl Swoopes.  And Katie Douglas. And Becky Hammon.  And Nykesha Sales.  And Kara Lawson.  And Tamika Catchings. And Lindsay Whalen.  The pioneers of the WNBA.  In most of those cases, I didn't just get to watch them play some exceptional basketball, I also met them, occasionally had meals with them, traveled the world with a few of them, and got to learn about basketball and how the women's basketball world works.  The game that they play is the same game the men are playing.  But the women's basketball world is not the same as the men's basketball world, and having an appreciation for how hard these athletes are working year-round is inspiring to me.

There are still basketball related items to check off my list.  I'm working on those.  If given the choice to watch the Golden State Warriors versus the Los Angeles Lakers, including a healthy LeBron James - or the Seattle Storm versus the Phoenix Mercury of the WNBA... I'd pick the WNBA game EVERY SINGLE TIME.  If you haven't been to a game, the season is coming.  Reach out and let me know when you want to go.  Add it to your bucket list.  Let's make it happen.