The rains are upon us here in Seattle. Gross! If you've never been here during the doom and gloom season, what you've heard is true. It's grey, dark, cold, wet, and everyone is a bit more cranky. (Or maybe that's just me?) But the leaves are beautiful to look at and the candles are lit and ALL the blankets are ready to get cozy and it's hot chocolate season... so that's all exciting. And what better way to hide from the weather than to take some continuing education courses?
This past weekend, I completed my fourth NAIOMT (North American Institute of Orthopedic Manual Therapy) course. I've previously written about my experience with these courses on the blog here following the last one I took way back in 2017. Since I started working at Seattle Children's Hospital in 2017 I've used considerably less manual therapy so these classes have fallen lower on my learning priority list. The kids don't tend to need it so much and I've learned so much about the impact manual therapy sometimes has on patients psychologically that even when I'm in the adult clinic, I'd prefer to use it less. As I continue to grow in my career, I keep learning what I like and what I don't which changes how I interact with patients. In general, I try to avoid "doing things to patients" and prefer to help them learn how to do things for themselves. That's not to say I don't use manual therapy at all... it just isn't my first step most of the time. I do occasionally work with adults and they typically have expectations of receiving this sort of treatment, particularly because of the way the clinics I work at organize their schedules. Sometimes they really do need it - but for sure not always. And in the State of Washington, physical therapists who manipulate the spine need a special certification with specific continuing education, so to maintain my certificate, I took this class.
Amanda Scharen teaching lumbar instability tests
To be fair, these NAIOMT courses aren't just about manual therapy, either. Sure, the photos I've included are of a manual technique performed by Steve Allen, NAIOMT faculty member and a Physical Therapy Historian who exudes love for the profession along with my friend and Director of Therapeutic Associates - Queen Anne - Amanda Scharen. I'll even quote Steve from this weekend, "Manual therapy is a small ut vital part of our practice. Combine it with exercise for the best outcomes." But these classes also include advanced review of anatomy and biomechanics, which is important when you haven't studied it specifically since PT School. There are many cases presented during the weekend which challenge clinical reasoning. The partiipants of NAIOMT courses are all physical therapists so there are really interesting discussions about evidence supporting different topics, sometimes even debates, and some of the scientific literature is included for participants to read ahead of time.
SI Joint - from Wikipedia
For example, this course included this paper "Evidence-Based Diagnosis and Treatment of the Sacroiliac Joint" from 2008. I had not previously read it, but did learn this in PT School. It describes the different tests you can use to try to identify if the joint between the sacrum at the base of the spine and the ilium (pelvic bones) is contributing to a person's pain presentation. During class this weekend, we had a discussion on whether or not this joint moves at all - as many believe that it is fused and therefore immobile. I personally believe that the SIJ does move for three reasons: 1) I have seen too many patients with pain that improves with changes in their pelvic positioning or with exercises training stability for this region 2) When I have a specific pain pattern, treatment to my own SIJ resolves my symptoms almost immediately, and 3) I don't think women would be able to give birth if this was an immobile structure. Doesn't really explain why it would be as mobile in males - but I don't usually see this as a problem region in men as much. If you're a PT who hasn't been exposed to the tests that may help identify the SIJ as a contributor to pain, the article outlines each one and presents pretty good psychometric properties when using them as a cluster. Interestingly, the author describes the tests and then admits that he no longer uses SIJ manipulation as a treatment because it tends to be unsuccessful. He recommends stabilization exercises and, if that is unsucessful, injection into the joint.
What I've come to understand more and more is that the healthcare you receive from any provider is biased to the beliefs of that provider. For example - if you came to see me and I determined that you had tight hamstrings, I tend to guide you to strengthen the hamstrings in an effort to relieve some of that tension. Some of my coworkers, however, would teach you how to stretch your hamstrings. There are articles supporting both methods. There are groups of people who support both sides. As a patient, if you don't have any prior knowledge on the topic, you're probably just going to take your therapist's word for it that they know what they're talking about. As another example - I've been experiencing some really annoying abdominal pain for the past several months. My GI doctor sent me for tests like an endoscopy and colonoscopy and is treating me for acid reflux. Yes, the medication made me feel better, but I didn't think that was the underlying problem, so I sought out another opinion. She's treating me for something entirely different. Her beliefs about my symptoms match more with my own beliefs of my symptoms and I'm far more optimistic that I'll have a good outcome with this method. As long as the patient gets better, does the method used to get there even matter? Regardless - the evidence is strong that for low back pain, physical therapy should be your number one choice for care. Not medications. Not injections. Not surgery. Not imaging. PHYSICAL THERAPY. Get PT First.
These are the things I think about during these dark Seattle fall-winters.
I have another continuing education class coming in two weekends. I'd imagine it will still be raining then... so a blog post about it is likely. It's very different from this one, so that will be a fun juxtaposition.
Yesterday was Game 3 of the WNBA Finals. If you're not familiar with this league, the Finals are a best-of-five series which means you need to win three games (out of five) to be crowned champion. Last year, the Seattle Storm swept the Washington Mystics 3-0. It was glorious! Right now, the Washington Mystics are 2-1 ahead of the Connecticut Sun, with Game 4 being held tomorrow night at Mohegan Sun Arena in Connecticut.
Why is this important to me? First, as the physical therapist for the Seattle Storm, I wish the Storm were playing in the Finals and that I was there to watch. I love basketball and this really is some of the best basketball you can watch. Haven't been to a WNBA game? What are you waiting for?!?! Second, despite being dedicated to the team I work with, I'm also a supporter of the league as a whole and have a long history with the teams currently competing. The current Head Athletic Trainer for the Sun, Rosemary Ragle, was the UConn Women's Basketball Athletic Trainer while I was in college - and also worked with me on my Grad School thesis. The current Washington Mystics Head Coach, Mike Thibault, hired me to work for the Connecticut Sun when I was graduating from UConn in 2007. I worked for him - and the Sun - for four seasons before PT School. Their assistant coaches include his son, Eric Thibault, and former UConn and Connecticut Sun standout and Olympic Gold Medalist Asjha Jones who were both with the Sun when I worked there. I can't possibly root for one team over the other - though I have a lot more Connecticut Sun t-shirts in my closet than Mystics attire.
So I'm following the WNBA Finals, watching teams compete for the highest position in Women's Basketball - perhaps falling only behind the glory of an Olympic Gold Medal or World Championship - and the headlines are riddled with descriptions of injuries these players are experiencing.
Like these tweets:
Alyssa Thomas has a torn labrum in BOTH of her shoulders.
Elena Delle Donne plays through injury to move Mystics one win from WNBA title
Washington beat Connecticut Sun 91-81, lead series 2-1
League MVP has a herniated disk pinching nerve in her back
Associated Press
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Elena Delle Donne drives the ball to the basket during Sunday’s game. Photograph: David Butler II/USA Today Sports"Elena Delle Donne put forth a gutsy effort, playing through a back injury, and Washington beat the Connecticut Sun 94-81 on Sunday to move within a victory of winning the franchise’s first title. The league’s MVP has a herniated disk that is pinching a nerve in her back and was questionable to play in Game 3. She finished with 13 points, hitting five of her six shots and played 26 minutes."
I can't help but thinking - what message does this send to the fans, particularly the young ones? Is this helpful? What does it all mean, anyways?
First and foremost, a disclaimer. I am not working with either of these athletes. I do not know what care they are receiving - but I would bet it's excellent from my years interacting with both organizations. I care about the health practices around the WNBA and have been trying to help improve their standards for several years - so from the research I've done, I can say with confidence that it is highly likely that these basketball players are being well taken care of.
Additionally, I absolutely 100% believe that the above-mentioned athletes with injuries are experiencing pain. I read one account that said that Elena Delle Donne could not sit down because it was too painful, so the medical staff and coaching staff had devised a plan to bring her into their locker room when she was subbed out of the game to keep her moving and stretching and to avoid extended periods of sitting time. This sounds like EXCELLENT collaboration between a medical and coaching staff and is something other teams should take notice of! (The Storm is good at this, too, in my opinion!) If an athlete is reporting pain, I believe that they have it. All pain is real. Pain is a personal experience that is influenced by many things. But pain is also a protector and it doesn't necessarily mean these athletes can't be playing. Here are my thoughts with what I've read and, more importantly, some thoughts on comments from fans who have opinions on the matter.
1) There are HUGE numbers of people with imaging showing torn labrums in their shoulders and disc herniations that DO NOT have pain.This paper discusses the labrum tears and found that 55-72% of people without shoulder pain had a labrum tear. (The population was a little older than Alyssa Thomas, aged 45-60, but she is an overhead athlete so this presentation for her is not really that surprising). Want something more specific to athletes? This blog post from fellow UConn Graduate and well-known strength and conditioning coach with Major League Baseball players, Eric Cressey, presented the research on the same topic. He quotes: "Miniaci et al. found that 79% of asymptomatic professional pitchers (28/40) had "abnormal labrum" features and noted that "magnetic resonance imaging of the shoulder in asymptomatic high performance throwing athletes reveals abnormalities that may encompass a spectrum of 'nonclinical' findings."This paper looked at a large sample (3110 subjects) without back pain and found on MRI that 30% of 20-year-olds have disc herniations and that the number increases over time. This is why sometimes people have surgery but it does nothing to correct their pain... because the MRI findings and the surgical correction does not always fit with the pain.
2) These are elite level athletes so it concerns me when I read that suggest they're "skipping surgery and playing through pain." Tissue damage DOES NOT correlate with pain, so unless ESPNw was given reports from the teams stating that they had pre-participation MRIs that were normal and then started having pain the correlated with tissue damage (which goes against a lot of the evidence) a surgery may not even come close to fixing these problems. Another way of looking at this is - why does their body adapt to present with the MRI findings that they have. For example (hypothetically) is Alyssa Thomas' upper back too stiff for her to get her arms all the way overhead to shoot and rebound? Because if that's happening, she's effectively cranking on her labrum to get her arms over head and then a shoulder surgery may fix her labrum, but it doesn't actually fix the initial cause of the problem. She'll still have a stiff upper back, so it'll only be a matter of time until the labrum is reinjured unless the real underlying cause is addressed. Why does everyone want people to rush straight to surgery, anyways? That's painful! As a physical therapist, my number one goal is to help athletes avoid having any surgery at all. Sure - if it's necessary, such as in the case of Breanna Stewart having an entirely ruptured Achilles tendon, we're talking about something different. But what if we just let these athletes recover after a grueling season (next week!).
3) Can we acknowledge the additional stressors of playing in the WNBA Championships? It is well known that emotional stress contributes to our experience of pain. Elena Delle Donne was injured during Game 2 of the WNBA Finals. Anybody else ever get injured at work and need to finish the shift or wake up with a super stiff neck or spasm in their low back and still have to go to their job the next day? She has a job to do and it's far more in the spotlight than most people's work. She'll get her symptoms managed and her pain will likely have a bigger impact on her job than on many other peoples' jobs, but she'll also participate in the conversation of whether or not she plays. Or at least she'll have her agent do it. Someone will be advocating on behalf of these players to protect their health.
Many of the comments online were about how she was forced to play. We don't really know that! Any chance these commenters considered that she chose to play once the medical providers told her she would be allowed to? The reality of this situation is that in less than one week the WNBA season ends, the physical and emotional stresses of the season will be reduced, and a period of relative rest (which means they don't just curl up in a ball in bed) can begin. What if they have some injuries, but they're also sleep deprived with elevated cortisol levels from their increased stress, not eating as healthy as usual with their family entourage visiting for the Finals and wanting to eat out? It's so much more complicated than just "an MRI showed some damage." There will be time to stay away from the basketball court coming soon, time to reduce the amount of stress on their bodies and their minds with decreased physical activity including, less jumping, decreased torsion and load on injured anatomy, maybe some extra napping, some gentle swimming or yoga, and globally allowing the nervous system to calm down. The Playoffs are three straight weeks of sympathetic Fight or Flight Mode... how about a nice parasympathetic Thanksgiving style dinner that puts you into rest and digest recovery mode? Maybe we'll see that no surgeries will be needed for any of them!
4) There are definitely circumstances where an injury to an athlete means they should not play their sport because it puts them at risk for further injury. For example, after experiencing a concussion, it is dangerous to the athlete's health to compete before all symptoms have entirely resolved. For example, if an athlete has a broken bone, not only could it be extremely painful to compete, but the athlete is at much worse damage with a subsequent injury. For example, if an athlete cannot control their bowel or bladder or they have muscle weakness or numbness/tingling into their legs or arms - these can suggest a much bigger problem with the spinal cord.
But there are many circumstances where an injury to an athlete means they will have pain while they do the things they love, but they may be OK to play with certain precautions. For example, someone who recently sprained their ankle may be able to play while wearing an ankle brace. The brace can protect from further injury while they are completing their healing. For example, in many states it is approved for someone wearing a cast with a broken bone to pad the cast and play sports anyways. The cast will protect the injured athlete from worse injury and the padding protects opponents from being hurt. A torn labrum of the shoulder may be associated with a lot of pain for Alyssa Thomas, but is she at risk for any sort of red flag event by playing through it? No. And, without knowing the details of Elena Delle Donne's injury, I suspect she's experiencing a lot of back pain without the neurological symptoms into her legs that suggest spinal cord problems and that her medical team has determined it is safe to be playing. She would not be on the court otherwise.
At the end of the day, tomorrow night could be the final game of the 2019 WNBA Season. If it is, the Mystics go home with a Championship. If not, they will play one more game. I personally want to see all the best players on the court at the top of their performance. So I'll send up some prayers for these two incredible athletes and role models and to all the other WNBA players currently having pain. And I'll be rooting for the Sun and Mystics medical providers who will soon get a nice rest break, too.
