2024: The Year I Didn't Blog

Happy New Year! 2024 has come and gone seemingly in the blink of an eye. Somehow I managed to read far more this year with audio books on faster speeds during my commutes and travels. I read so much – and wrote a little bit in other places – but I didn’t write any blog posts here! I’ve missed my blog and hope to return more in 2025, but I'm also planning on writing a book! Now that I'm sharing that with everyone, hopefully this will keep me committed to the goal. 

My first book will be "It depends." Anyone whose gone through PT School - or probably any professional medical education - will likely tell you stories of how they asked questions in school only to be repeatedly told, "it depends." Though frustrating, with the hindsight of a decade of clinical practice, it's now a lot easier to recognize that this is the best answer, and now I can come up with a whole host of considerations that the question would depend on. This is a chance to tell some clinical stories to shed light on why working in healthcare is so complex, and also highly entertaining. So hopefully I'll be able to write the book while keeping up with my blogging!

Early in 2024, I was invited to give some talks at different conferences, so I dedicated the early part of the year to a lot of reading and developing those presentations. The biggest talk was alongside colleagues Dr. Karen Litzy and Dr. Devra Sheldon at the American Physical Therapy Association Combined Sections Meeting in Boston about Complex Regional Pain Syndrome. I also spoke at the TRIA Orthopedic and Sports Medicine Conference in Minneapolis about Rehabilitation for the Adolescent Athlete thanks to an awesome colleague recommending me for the job. In 2025, I'm working on giving a talk at the Seattle Children's Hospital Rheumatology Conference where I'm partnering with a physician and we're talking about differentiating between rheumatological conditions and chronic sport-related pain in young athletes. 

My writing in 2024 was limited, but looking back it was all fun. I wrote three articles for The Next Hoops and some blog posts for Pain Geeks. The Next publishes everything you could ever want to read about women's basketball. They're fantastic. If you're a fan of the WNBA or any college team, I highly recommend you check them out and subscribe. My articles for them included coverage of last year's Apple Cup where University of Washington played Washington State University, something that will be more difficult to achieve as the college conferences were realigned heading into this current season. 

I also teamed up with fellow physical therapist and writer Lucas Seehafer where we reviewed the 2023 WNBA injury stats heading into the 2024 season.  I'm excited to continue to partner with Lucas in the future as more data is collected and hope that next year, the League manages to stay healthier! 

My final piece for The Next was an exploration of how the WNBA medical staffs have been expanding as the League has been growing. It included spotlights on several of the medical providers around the League.  It gave me a chance to meet new athletic trainers, physical therapists, and strength coaches working in the WNBA as well as to catch up with some of the providers I have known for more than 15 years. They're an awesome group of people and it was really fun giving them the spotlight, though most of them are pretty happy being behind the scenes. 

For Pain Geeks, I was invited to lead their fall book club discussion choosing the book, "When Breath Becomes Air" by Paul Kalanathi. For this I wrote two blog posts leading up to the meeting. Part 1 and Part 2. The book is gut wrenching and heart breaking while simultaneously beautiful and inspiring. I rarely read books twice, but I really felt that this one deserved discussion and it was fun chatting about it with the other Pain Geeks. PT pals - if you're working with patients experiencing chronic pain and want to really grow your community of medical providers, the Pain Geeks are all over the world and our group meetings continue to make me a better clinician. Check them out. 

I guess since I've mentioned a book I loved in 2024, I'll also write about what I read last year. Thanks to audio books, I broke personal records completing 76 books! Incorporating a bit more fiction seems to make me read faster, and I read more of those than usual because several people kept telling me to jump into Sarah J. Maas's books. Let me just get this out of the way: I liked the "A Court of Thorns and Roses" Series. I did not like the "Throne of Glass" series and didn’t finish it. I like other genres far more than these and don't know if I will read any romantasy in 2025... but if that's your jam, please do enjoy it! I can already feel the daggers coming from some of my friends who thought these books were  life changing. Sorry, friends!

What books did I like the best in 2024? 

I listened to several biographies or memoirs and also read a few. In a lot of cases, the narrator was also the author and I love when that happens. Incredible athletes like A’Ja Wilson who shared her relationship with her grandma alongside her basketball journey made me want to root for her even though she’s not on the team I cheer for. I felt like The Terminator was sitting in the car right next to me as Arnold Schwarzenneggar described his childhood and how he ended up in body building. It was so much better than hearing my own internal monologue. Dancer/actress Kelly Bishop’s tales of her life and career on stage as the main character in A Chorus Line before she became Emily Gilmore, matriarch in Gilmore Girls. I learned a lot and as a Gilmore Girls fan was so glad she read it herself. My heart broke learning about Britney Spears and how she was basically tortured by her parents and also hearing Matthew Perry describe his ongoing battles with drugs. And there were several others that were all really fantastic, but these were the most memorable from that genre.

I read several books about Israel, Gaza, antisemitism, Judaism, and Hamas. In the wake of the October 7, 2023 massacre at the Nova Music Festival, I found myself involved in numerous conversations about the Middle East, a place I have been, a place  I lived and worked as an Emergency Responder, and a place that is very important to me. "Israel" and "Uncomfortable Conversations with a Jew" both were filled with detailed history of the conflict, but I thought it was important to read from a different perspective. For that, I read “Son of Hamas” and “I Shall Not Hate” as well as some graphic novels about the Middle East.  

In the past, I primarily read non-fiction books, but I do love fiction and my temporary commitment to
flying faeries was fun for a while. I think my brain needed somewhere to chill out after all the journal articles and novels helped me recover. My favorite non-fictions this year came from Emily Henry and Taylor Jenkins Reid and I've been working my way through another Greg Iles book that's super long but I love his work. I also liked, "Everyone in my family has killed someone" by Benjamin Stevenson.

And my favorite non-fictions this year were "Rare Gems," by Howard Megdal - Minnesota Women's
Basketball History at its finest, "Unreasonable Hospitality," by Will Guidara - which aligns with my commitment to therapeutic alliance with my patients and going out of my way to make others feel special. Though it fits as a memoir, Kate Fagan's "All The Colors Came Out" where she talks about her basketball life along with the relationship it facilitated with her father was perhaps the best book I read all year. Tears and laughter. 

So there's 19 of my favorite books from last year... and it was even hard to choose those! 

What am I most excited to read in 2025? 

Biographies: Maya Moore's Love and Justice and Brittney Griner's Coming Home

Fiction: the new prequel for the Hunger Games that explores the back story of Haymitch - Sunrise on the Reaping - by Suzanne Collins and novels by Abby Jimenez

Non-Fiction: Jay Shetty's 8 Rules of Love and Louis Gifford's Aches and Pains series. 

I like to read a classic and/or banned book and this year I think it'll be Brave New World. 

Beyond that - here's to lots of fun 2025 travels and meet ups with friends with outings planned in Maui, San Francisco, and Austin already... but more for sure to come.  Who wants to get together?  Let's make some plans! I'm sure there will be plenty of basketball games to attend, hopefully some more Goo Goo Dolls concerts, and fun adventures around the PNW.  Happy New Year, all!

Zoe and Zak's Adventures to meet the PNW Trolls

With my niece, Zoe, at the Fremont Troll

A few months ago, I was scrolling my social media when I came across a post announcing completion of the installation of five Dambo Trolls in Washington. These trolls are large pieces made from recycled materials designed and constructed by Danish artist Thomas Dambo. An unrelated troll has resided in Seattle under the Fremont Bridge since 1990, originally intended to deter homeless people from living in the area, which was a few blocks from my apartment when I moved here. I took many visitors to mee the 18-foot tall Fremont Troll sculpture, but didn't know if trolls had any significance to the area. Washington is more associated with Sasquatch (AKA Big Foot), and my research has shown that trolls aren't really connected to the PNW, but these new masterpieces seemed interesting, so I decided to visit them. 

1990's Troll Toy

I also decided to learn more about the history of these fantasy creatures. I remember liking The BFG (The Big Friendly Giant) by Roald Dahl, who wrote my favorite book, Matilda, but have no recollection of reading tales of trolls. My brother used to have a collection of trolls when we were little, with the famous neon pointed hair and gemstone belly buttons.  Interestingly, those troll toys were invented by a Danish man named Thomas Dam, and these led to the creation of the Trolls movies that star Justin Timberlake and Anna Kendrick. I couldn't figure out if Thomas Dam was related to Thomas Dambo, but those names are way too much of a coincidence if they're not family.

According to Wikipedia, Trolls come from Nordic Folklore and Mythology and the word has a few different possible meanings including fiend, demon, or mythical magician. Trolls typically live in isolation, in forests, mountains, or caves, and Dambo shared that his installations use recycled materials to help the planet and bring people outside to visit nature. He's creating a "bridge between cultural and environmental stewardship." As I read more about trolls, I thought about childhood adventures and fantasy tales, but the isolation so frequently depicted also reminded me of some of my patients with chronic pain. I frequently work with teenagers experiencing chronic pain or illness, and it's common to see them isolate as their condition worsens, transitioning into a period of hibernation.

Zoe and Zak's Pain Hacks

I decided to write about the five trolls along with a review of a new children's book series written by Dr. Joshua Pate, an Australian physiotherapist, called "Zoe and Zak's Pain Hacks." (Link to buy in the US.) Dr. Pate has written a TED talk called "The Mysterious Science of Pain," that's a great five-minute video clip.  

I first learned about Dr. Pate and his work with kids experiencing pain in November 2021. While preparing to give a talk to coworkers at Seattle Children's about treating kids with chronic pain, I couldn't find research indicating what age kids start to understand the pain neuroscience concepts recommended by the Explain Pain Books so frequently shared with adults. I tweeted what I was searching for, and Dr. Rachel Zoffness came to my rescue. 

Not only did Dr. Pate send me a copy of his (soon to be published, now available in a book) chapter called "Developmental Influences on the Meanings of Pain in Children," he offered to meet for a Zoom chat. He was very kind to spend an hour chatting with me about the work he was doing and that he had this series of children's books coming out soon. His research, and there's loads of it!, determined that kids start to understand pain concepts around age 8, and he also explained how he conducted some of his research and some of the interesting things he had discovered. I found his reference to this paper where children were asked to draw whatever the word "pain" made them think of particularly memorable. Dr. Pate found that in his small sample of kids, those who were experiencing chronic pain drew emotional components like a broken heart or tears, which kids who did not have pain did not draw.  

Pia the Peacekeeper

The boxed set of books arrived at my home soon after our call and I read them right away. They're beautiful and fun to read, despite being about pain. I started to write a blog post about them way back then without the trolls, but the post felt like it was just me spitting out pain research and I prefer to write my posts connecting different thoughts, so I stored the books on my shelf, alongside my other fabulous pain nerd books, until the epiphany came to pair the books with the trolls. So here's Zoe and Zak Zoppins on their adventures with me as we met the PNW Dambo Trolls.

The first book in the series is called "Zoe Zoppins Nails It." It tells the story of "A Tale of Two Nails." Zoe's Uncle Ozzie steps on a nail and has intense pain, only to later find out that the nail went between his toes and didn't injure his foot at all. This story is commonly used to show that pain doesn't always equal tissue damage, and the illustrations and rhyming make it easily understood even at a young age.  The first troll we visited was located on Bainbridge Island, across the Puget Sound just a little bit west of Seattle, and is named Pia the Peacekeeper. Located on Salish territory, the Muckleshoot and Snoqualmie tribes collaborated on the development of Pia. These trolls are quite massive, and I had an immense appreciation for the size of their hands and feet. Having Pia hold the book was the best way to demonstrate the scale, but of course my nerd thoughts went to the homunculus and how much sensory input these trolls would have from their massive hands.

Frankie Feetsplinters

Second in the series is "Zoe Zoppins Lights It Up" which is based on this research from Lorimer Moseley, author of the previously mentioned Explain Pain Books and mentor to Dr. Pate. This study examines pain under different contextual circumstances. Zoe is tapped on her hand by a cold metal rod and rates her pain when there is either a blue or a red light shining in the room. When the blue light shines, the pain is less intense, but when the red is illuminated, the pain increases. I wonder if Dr. Pate chose this book to have a blue cover because of the storyline. Similarly, I recently participated in the 30-day course The Embodied Clinician with Sheren Gaulbert who I met at the San Diego Pain Summit. We also discussed the relationship between colors and emotions, so naturally I sought research on this topic and found this paper, which suggests this science is in its infancy, but that red has been studied and found to relate to increased attention and outward focus and potentially has an impact on performance. 

Jakob Two Trees

The second troll I visited was Frankie Feetsplinters who lives in Ballard, a Seattle Neighborhood that houses the Nordic Museum. It makes sence that this would be the location for one of the trolls, as the Nordic countries include Denmark, home of the artist. Frankie was the last of the PNW trolls to be installed and was assembled in West Seattle and transported on a flatbed truck to Ballard. The blue-grey skies of Seattle and the more welcoming pose of this troll were certainly not scary. I've never actually gone into this museum, but I hear great things about it and have tickets to check it out in early 2024. (Seattle pals - you can get free tickets to many museums through your library card or directly through the museum! The Nordic Museum has free tickets on the first Thursday of every month).

"Zoe and Zak's Brainy Adventure" is the third book in the series.  I think the illustrations in this one might be my favorite from the set, though the art is really great for all of them. This story explains the numerous messages that are sent and received when an injury occurs and how quickly they're processed, all contributing to pain which is meant to protect us. In an acute pain situation, the protection from pain is helpful, but in a long-term situation when the pain persists, it can become over-protective. This story shares many Explain Pain concepts, like "Pain does not always mean tissue damage." It uses virtual reality to explore the brain, though it doesn't go into detail about how virtual reality can be used for pain - maybe that will be in the second series if Dr. Pate keeps writing these! The third troll I visited was Jakob Two Trees, located in Issaquah, who is simply magnificent at 14-feet tall. I think Jakob was my favorite troll - a short walk among the trees that protect you from the rain, just like pain is protecting our bodies - but there were SO many people visiting, that it was hard to get a close-up photo. It was really fun meeting others who were Troll Hunting on these adventures. 

Oskar the Bird King

Book number four is "Zak Zoppins Retrains His Brain." Zak is Zoe's cousin who shares that he has back pain while they're playing. They discuss how pain can change and isn't permanent using different strategies such as calm breathing and imagery to re-train the brain when it's used to having pain for too long. This is an important message to use with kids with chronic pain because a lot of the time they're fixated on their pain being permanent and that there isn't any hope for it to get better. They're not yet exposed to slow and steady progress for most things in life and are more immediate in their thought patterns, particularly the younger they are. This book, along with the previous and next ones don't refer to a specific research paper, but rather encompass many studies about pain. If you search for "Retrain Pain," you'll come up with several papers, including an online company, that offers a certification for rehab providers which looks interesting (though I'm not familiar with it, so I can't recomend the program).

The fourth troll was Oskar the Bird King, located on Vashon Island. Oskar was the farthest troll from my house and of course it wasn't raining when I departed, but by the time I arrived, it was POURING. Typical Seattle. Oskar is the most intimidating of the trolls in the PNW, pointing at you and with eyes that seem to follow you no matter where you're standing. He's just as awesome as the others, even with the rain, but I didn't want my book to get wet! It's hard to tell from this photo, but Oskar is wearing a crown of birdhouses and sitting on a throne. There are actually birdhouses near the other trolls and Thomas Dambo's earlier work was to install birdhouses all around Denmark. He uses scraps of material from making the trolls to create the birdhouses and at some of the locations, they are painted and posted to indicate the troll is nearby. 

Bruun Idun with the whole set

The fifth and final book is "Zoe Zoppins' Action-Packed Action Plan." In this story, Zoe shares her action plan to use if she's having pain and applies it to different scenarios, like her belly ache when she's nervous about giving a speech in school or when she gets hurt playing soccer.  It's got some similarities to the previous book in that it's sharing some strategies that might be helpful for a kid experiencing pain and how to try to treat it. I particularly liked the focus on all the different activities that Zoe CAN do, rather than on things she can't because of her pain.  This is an approach I frequently use, encouraging patients to participate in whatever they can, particularly if it's fun, as the activities might help reduce their pain in the long-term. 

And the last troll I visited was Bruun Idun, located in the most scenic setting of the PNW trolls in a coastal spot of Lincoln Park in West Seattle. If you plan to go visit, you could take an easy walk from the parking lot, or you could have no sense of direction like me and turn it into a nice two-mile hike through the woods, culminating in a gorgeous view. Bruun Idun is playing songs for the orca whales living in the nearby Puget Sound. Music is one of the things that I often use with my patients with chronic pain as something to help them move and sometimes even let out their feelings.  We talk about matching music to moods, yelling along with songs that help them let out frustrations or crying along with songs that might also be sad. We talk about trying to go for walks that last the length of their favorite song as a way to incorporate movement throughout their day, potentially including the distraction of pairing it to something more pleasant if the movement is uncomfortable. And sometimes, I give patients the homework of listening to their favorite songs and coming up with lyrics that are positive for them to post around their house as a reminder of better days to try to bring hope and momentary happiness. Everyone could use more joy in their day, but sometimes when kids are sick for so long, it's really hard to find that. 

All in all, it took me three months, four ferry rides, and one very wet outing to complete my visits to all the trolls. Zoe and Zak's tales helped me to think about pain from a different perspective and taking them on adventures helped me to enjoy the PNW in the early part of this year's rainy season. I'm hoping to make a trek down to the Portland, Oregon Troll, Ole Bolle, who is 19 feet tall at some point, but of now, thanks for the good reads, Dr. Pate, and thanks for the beautiful artwork, Mr. Dambo.

Let's Talk About Grief, Baby

I'm pretty sure when Salt-N-Pepa wrote this memorable song "Let's Talk About Sex" in 1990, they didn't think it would be parodied by a tiny blog discussing grief.  Have you ever seen this music video? The lyrics begin with "Yo, I don't think we should talk about this. People might misunderstand what we're trying to say, you know?...  Ya, but that's a part of life..." I think we need to talk more about "all the good things AND the bad things," which includes death, dying, and grief. The idea of "not talking about something" makes it scarier and allows for stigmatization.  There should be no guilt or shame when it comes to grief, but for that to happen, we need to talk about it.

The Fam <3

If you happen to know me IRL, follow me on social media, or you've read my previous blog post here, you know that both of my parents died from complications from Covid-19, fourteen days apart, in December 2020 and January 2021. (Get vaccinated already, for heaven's sake!)  In the same year, my family also said goodbye to my Uncle Pete (November 2020), and my Aunt Marilyn (my mom's sister, November 2021), not related to Covid-19, but terribly sad just the same. They're the four seated in the front row of this photo from our family reunion a few summers ago, all too young and too special to be gone. In the year this was all occurring, there has been incredible love and kindness towards my family and to me, including gifts of several books about grief. Now that I've read them, this post shares a little about each one, hopefully helping you if you're grieving, or if you're wanting to show you care to someone who has recently experienced loss.  

Source.

First, a definition.  There are many- but what stuck out to me was the third bullet on this one: Grief is "a NORMAL, natural, necessary, and adaptive response to a loss."  I initially felt entirely crazy in my grief. I was a different person and couldn't recognize myself.  Nothing about the grief experience feels normal. I started running late and losing track of time when I'm typically way too early for everything.  I forgot about commitments, getting texts asking where I was, only to realize that I totally spaced it. I said no, when I typically would say yes. I didn't want to help other people, and that's what I do for a career, and typically love. I was angry, I cried hysterically in the middle of Target, I had to pull over on the side of the road because I couldn't see through tears to drive, I couldn't sleep - when normally I'm the ultimate sleeper, I couldn't get out of bed, I stopped cooking, and I went into isolation. I'm about as extroverted as it gets and I didn't want people around me. These behaviors were far from my normal, so for someone to say it was a "normal" response was helpful. 

If you're also grieving, it is likely that your experience will differ from mine.  My brother, sister, and I were going through it together, but we each had (and still have) different responses to our losses. It doesn't do ANY good for us to compare to each other, because the person you're grieving held a personal meaning to you, and the family members I'm missing held personal meaning to me.  I talked to my mom on my drive home from work 3-4 times per week for seven years.  The drive home form work is one of the worst times ever for me... my brother doesn't have that same experience.  Fortunately he'll answer if I call him at that time, knowing what's going on.  Even for the family members grieving over the same people, the hole in your heart and soul doesn't feel the same for each of you. For me, grief has been fear and anger and frustration and sadness and confusion and loneliness all rolled into a ball. And pain. So much pain. I've written many blog posts about pain in the past, but grief is the first time I've experienced so much pain that was 100% connected to my psycho-social experience. There was nothing wrong with the anatomical structure or physiological function of my heart, but there was SO much pain and it was very real. (Come to find out, about 3 months after my mom died, I was diagnosed with pulmonary emboli - so it's possible that there was something going on anatomically, then, too, but that's a story for a different day.) None of my learning about pain prepared me for the pain of heartache.

All the pain and emotions came with gratitude, appreciation, reflection, and love for the people we lost and those who cared about our family. I hope that in your grief, you can find these positives - but they don't shine through every day. At the beginning, almost all of the days felt very dark, with very little time for light. As time has passed, there has been more time for light, and the dark has been less frequent and less intense. Perhaps you'll find one of these books or an idea in this post to be helpful for navigating this unmarked territory. Or at the very least, maybe you'll laugh at something in the music videos and have a brief period of light to disrupt your dark. 

Purchase Here

Book #1; "Healing After Loss" by Martha Hickman was the first grief book I started reading about two weeks after my mom's funeral. A good friend from high school who experienced heartbreaking loss sent it to me with the sweetest note. "Abs - people sent lots of stuff after what happened. This book was the only one I could handle. Short and simple. One page a day. If it helps, great. If not, use it as kindling.  Love ya." <3 My sister actually received it as a gift from one of her friends, too.

I have so much gratitude that I was able to take a leave of absence from work because I could not have been a functional physical therapist - or human - during that early time.  At the beginning, I know I was breathing, but I wasn't really alive.  I would see my therapist and she would ask me how eating, showering, and sleeping were going, and would ask if I had done any body movement at all.  We decided focusing on those basics initially was the best way to go, and beyond those, I set the goal to read a single page each day.  Accomplishing that goal was the first step to a long pathway back to returning to life. This book is set up like a calendar, one page per day of the year with a quote and a meditation related to grief and loss. In the beginning, I didn't have the ability to focus. For someone who reads about 40 books per year, it shocked me that I couldn't read a full sentence, let alone pages or chapters. My mind would wander or I'd just end up staring off into space. I spent a lot of time in the fetal position and, at the recommendation of my cousin, watched the entire series of Lost to occupy time and distract me between phone calls with my family. A book where I could read a single page was ideal - and honestly sometimes I had to re-read the same page several times to get through it and retain anything. Some of the quotes felt applicable and helpful.  Suggestions to move my body to get me out of my head - even if it meant getting up to get a drink of water and then curling back up buried under a pile of blankets. Acknowledgements and appreciation for the people who've been lost, knowing that early on, that's really hard, but that as time passes, the memories won't be as sad and there will be happiness and joy recalling time we spent together.  Recognizing that grief is hard and heavy but that there is life to live if you can manage to move through it is a common theme.  I liked this book, but also read it a page at a time, and once I returned to work, I sometimes would miss a few days, so I still have some left to get through, but I'll finish it eventually.

Book #2:

Purchase Here

My therapist gave me "It's OK That You're Not OK" by Megan Devine. She recommended I purchase this book a few times, but I couldn’t put myself together enough to order it or get it from the library. I was still having all my meals delivered and not leaving my house except to see her every week. Beyond basic survival, I didn't do anything except watch Lost and talk to my family with occasional friend visits, still incredibly fearful of the stupid Coronavirus. So when I arrived at a therapy session, about two months into my grieving, and she handed me a copy of this book, I finally understood how much she thought I'd benefit from reading it and by then, I was capable of reading for longer stretches.

This book was really good because it presents a first-hand experience from the author, who is a therapist, who suddenly lost her husband. She shares her grief and lets you find places where it matches your own. She shares many of the things commonly said to someone who is grieving and explains why some are helpful - and others are painful.

What I'm writing here is what I experienced, but the book explains similar situations, why they're painful, and what to do instead. For example, at the beginning, nobody else could understand what my siblings and I were experiencing. Tons of people said "I can't imagine what you're going through." I have a shoebox full of condolence cards that say that sentence. It's probably an accurate statement, said with good intentions, but instead of saying this, people could have asked what I was experiencing, helped me to process in some small way, and share in my grief. This is semantics... but as I preach in healthcare, the words we use matter, and these circumstances cemented that belief in me. Another common case of good intentions but hurtful words in our situation was "at least they're together." Remember, my dad died, and then fourteen days later my mom did, too.  I don't know about my brother and sister, but initially, I tried to find solace in knowing that they were together, but that never made me feel better. They didn't both need to die. Why couldn't my family at least have one of them, still? 

From "It's OK that you're not OK."

A few people told me they didn't know what to say to me, but they planned to keep showing up hoping that it was good enough. Trust me... it was. It is. The random text messages of my friends' kids on their back yard swing set, late night phone calls, invitations to get together even though I would likely decline, just dropping by to say hello, bringing over homemade dinners, offering to pick up Dairy Queen since you're going with your kids and they'll be quiet eating it in the minivan long enough for you to give me a quick hug? Asking how I was and not accepting "fine" as an answer, making me truly share how I was, and telling me that it was OK to cry, despite my embarrassment... that mattered. Those were really thoughtful and helped me feel like I wasn't forgotten while I wasn't able to live my own life. Friends took care of my house and made sure my mail was picked up, plants didn't die, and had a house cleaner come in while I was traveling for funerals. Showing up, however you do it tells the grieving person that you know they're hurting, and that you're willing to sit with their pain. You're not trying to take it away. You're keeping us company while we try to find air in our lungs. It's proof that we're not alone. Asking about memories so we can feel our loved one with us is even better. A grieving person is thinking about their loved one non-stop anyways... you bringing it up might be hard, but it provides for an outlet.

Purchase Here

The end of this book contains a short essay "How to Help a Grieving Friend."  My favorites: "4. Be willing to witness searing, unbearable pain." "5... Your friend cannot show up for their part of your relationship very well.  Please don't take it personally, and please don't take it out on them."  and "6... Do not say 'Call me if you need anything,' because your friend will not call.  Not because they do not need, but because identifying a need, figuring out who might fill that need, and then making a call to ask is light years beyond their energy levels, capacity or interest." Saying "What can I do" to someone who has a gaping hole in their heart doesn't work. They want their loved one back - nothing you can do will achieve that. Want to bring over a meal?  Offer it on a specific date and time. Want to sit with your friend while they cry? Tell them when you plan to show up. Send a note, a drawn picture from your kids, a text message just saying you're thinking about them. Recognize that your life is continuing with little change, but theirs is frozen in time.  

Book #3: 

Another friend send me this book, a favorite in her family, that is an illustrated story about, "The Boy, the Mole, the Fox, and the Horse." It's a sweet story about kindness and friendship with beautiful drawings.  Though it's the shortest book of the group, it took me a while to be ready to read it because the cover felt like it would be sad, and I was already sad! This one can be read as a book or you can just open up to a page and enjoy the individual messages - it's designed to be read either way. It probably would be a good choice early on, particularly if you're not capable of concentrating very much. And then I sent it to a friend who experienced loss of a special pet, and she seemed to really appreciate it, too. 

Book #4: Last but not least, "Finding Meaning." arrived with a note recommending I wait a bit before diving in and reminding me how many people cared about me. Ten months into life without my parents, I decided I was ready to read it.  I sat in my therapist's office telling her that we were nearing a year of grieving, that I thought it was time for me to decrease the frequency of our sessions after getting through the anniversaries, and that I was going to read my final book about grief before moving on. And then I read Chapter 2 of this book which shares that grief doesn't end at a year or any arbitrary length of time. When asked "how long should someone grieve," the answer is "as long as I'm alive without the person I loved."  It may not hurt as much or as frequently, but that emptiness and sadness exists and can be triggered forever.  The book uses this as part of it's main theme - that Kubler Ross' 5 Stages of Grief end in Acceptance, but that she missed the 6th stage: Meaning. Meaning in the life (lives) that have been lost and in your own life moving forward without them.  Meaning helps make sense of grief.  It can look like gratitude, commemoration, honoring, shifting behaviors after the realization that life is short, or something else entirely.

Purchase Here

Finding Meaning shares the benefits of expressing your grief.  I've written about my grief once before, and spoken about it quite a lot, including discussions with my family about my preference to continue including my parents in our future life experiences, even though they're not here. Some people lose loved ones and they keep their emotions inside and private.  That could be ok for them, but it isn't what feels right for me.  I wouldn't be who I am if it hadn't been for the way my parent's raised me. They'll always get a little bit of the credit for whoever I become, and I will intentionally acknowledge that. This book seemed to examine death more than the others. How our society looks at death as a failure - despite the fact that 100% of people die. It explains that grief is inevitable where there was love, but that suffering is ultimately a choice that we can individually control, though that seems impossible at the beginning of this road. I know I still experience moments of suffering, when the pain overtakes me as I accidentally go to call my mom on my drive home from work, or I want to ask my dad a question, and forget for a moment that I can't. I don't suffer as much as I did before, and I think it's important to share that for anyone who might be grieving and comes upon my post.  Yes - I miss my parents - every single day, but I can continue living and keep them part of my life even though they're gone.

Honorable mentions: I also read Michael Rosen’s “Sad Book,” a book about grief appropriate for little kids written about the loss of his son, and Tom Hart's “Rosalie Lightning,” a graphic novel with incredible artwork depicting the loss of his young daughter. While all of these books helped me in different ways, I didn’t read any specific to loss of a parent, and definitely not two of them fourteen days apart with the added loss of two more close family members, and for certain not during a global pandemic where it was impossible to mourn with the rest of our family.  I would think more people lose parents than spouses or children, but maybe they're not usually as traumatic and they're more expected that less books are written about that?  Above all, I’m so grateful for these gifts, particularly the notes that accompanied each of them, and I can appreciate that others, including many in my family, have felt loss in a deep way this past year.

Added June 9, 2022: At the suggestion of a friend who was also experiencing grief, I read "Welcome to the Grief Club: Because you don't have to go through it alone" by Janine Kwoh.  New in 2021, I was already a year into my grief process when I read it, and liked it.  This book was different than the others and deserves inclusion in my post because it was helpful, supportive, validating, and used multiple mechanisms such as a short page or two of text, questions with answers, characters with speech bubbles, and even graphic representations to help process thoughts and emotions.  I think I would purchase this one to send to someone experiencing grief because it was easily digestible in small chunks, and, considering the topic, it was the easiest to relate to. 

Typical of me, this post has gone on far longer than I intended.  Music often enhances situations, but the anthem of this post can't be "Let's Talk About Sex."  At my Aunt's funeral, my cousins chose to play "You Are My Sunshine," which my Aunt sang to them - and my Mom sang to my sister, brother, and me. I couldn't believe the snow that started falling while a song about sunshine was playing. For me, I tend to cling to a song during emotional times, particularly if the lyrics seem to fit the situation.  Later on, if I happen to hear that song, I flash back to that time and appreciate the memory having a theme song to accompany it. Since my parents died, I've been cherishing the comfort from my family and my oldest friends, and so for many months, I've been playing Ben Rector's "Old Friends" on repeat. Those friends who are more like family, like my cousins who also feel like friends, all of which knew my parents. People who were sad about what was happening for their own reasons and grieving alongside me. I think people who are sad need to find what feels most comfortable, and for me this was what felt right. "Cuz no one knows you like they know you and no one probably ever will, you can grow up, make new ones, but the truth is, there's nothing like old friends... I've got some good friends now, but I've never seen their parents' back porch. Wouldn't change how things turned out, but there's no one in this time zone who knows what in-line skates I wore..." Some awesome lyrics on repeat for many months filled with sweatpants, blankets, tea and LOTS of tissues and FaceTime.  So why not post two different songs with entirely different tones and messages to round out the same blog post? 

If you're grieving, I'll keep it real and tell you this sucks. So much. And it hurts, right where your heart is beating in your chest. But it's normal to feel this way if you've had love in your life. You're not alone. And while you'll continue missing your people, there is life worth living even without them, and you can bring your memories of them along with you.  Take photos with your loved ones when you see them next... you'll be glad later.  And tell people you love that you love them. 

If you need help, here's the Crisis Grief Text Line for you to get help right now.

Sending love to Aunt Marilyn, Uncle Pete, Mom, and Dad. Always. TTHAS. 

Book Alert! The Gift of Pain

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

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

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

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

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

Free photo 96827 © Chrisharvey - Dreamstime.com

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

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

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

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

To Clam, or Not to Clam

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

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

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

Key point number one: The Clamshell Debate.

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

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

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

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

Point Number Two:  What research should I be reading?  

Levels of Evidence - Creative Commons CC BY-NC 3.0

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

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

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

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

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

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

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

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

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

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

Free photo 5470017 © Pavel Losevsky - Dreamstime.com

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

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