Breaking Up With My FitBit

My Only Half Marathon

Towards the end of 2017, a friend asked me if I would be willing to commit to running 1000 miles in 2018 as a motivator for her training for some half marathons.  She's a good friend... like really good... like one of my favorite people on the planet... but that was an easy question. Heck no!

I'm not a runner.  In fact I think I hate running.  I can run. As in, if a bear was chasing me or I happen to be facing oncoming traffic, I could get out of the way at a faster pace than my usual walk.  I have run road races in the past - including running our first half marathon together.  There's a chance I'll run a 5K again... those are fun.  But after we ran the half marathon, she just continued running them.  She's probably past 30 half marathons by now.  I didn't run another... and I can't imagine I would.

There are so many ways to exercise that it's not a big deal that running isn't on my list of choices.  Occasionally at the gym I choose the treadmill and get in an interval training session instead of a bike or elliptical, but in general I choose lifting weights and a class whenever possible.  I think the only time I really choose to run is when the weather is nice and I can be outside or I'm exploring a new place.

So I agreed to completing 1000 miles on foot with the goal being to walk that many miles in a year... and she would run them.  I got a FitBit that I wore pretty much every day for 2018 to track my progress and it was really fun.  The FitBit app lets you cheer others on and does some fun things when you meet your daily goals.  I completed 1000 miles towards the end of September and felt like wearing the FitBit tracker definitely motivated me to go a little bit further.  If I was wrapping up my day and it said anything over 9,000 steps, I almost always found a way to wander the house to hit that 10,000 step milestone.  I jogged in place reading a book that was resting on top of the laundry machine or paced the hallway back and forth listening to a Podcast just to finish that last 1,000.

There were certainly a few days where I did next to nothing... but overwhelmingly it increased my motivation to move.  When I looked back, there were only 5 days in 2018 where I walked less than 1 mile.   There were also a few days when I walked more than 10 miles in a day hiking.  So those are balanced out, right?  I started walking on my lunch hour a few times per week and when my job relocated to a much larger building, my step count increased just by having the bathroom and lunch room considerably farther away.  I really liked seeing how the tracker affected me and how the job change affected my movement.

But now it's 2019, and the FitBit is no longer on my wrist.  There's two reasons for this change.

First - I've decided it's time for my body to tell me when it wants to move... not a machine.  Some days after work I'm just downright tired and don't want to go to the gym.  I'm tired of making myself feel guilty for taking a day - or even a few days in a row - off from exercising.  I think I may have been torturing myself a little last year to make myself move more than felt good for me.  And... when you're on the stair climber or the elliptical at the gym, if you don't move your arms enough, the Fitbit didn't register it so it's like you didn't work out, and then a stupid machine was making me feel bad.  I'm not into that.  Funny enough, if I type aggressively enough during the work day, the FitBit also recorded key strokes as movement...and that's just ridiculous.  Sometimes I just type with purpose!

"A Beautiful Mind"

Second - I tracked everything I did last year.  Every mile I walked.  The food I was eating.  Workout days, stairs trained, progress towards personal goals, even the books I read. There's a beautiful thing about tracking in that it shows a lot of accomplishment and completion of tasks.  There's also the opposite effect - I was intimately aware of all my failures.  I set some goals that were not reasonable and every time I noticed how far I was from achieving them, I felt bad.  My 2018 planner looks like John Nash's office in "A Beautiful Mind."  Circles and lines and random numbers with symbols for workouts everywhere.  The tracking needs to go.

So... if I go for a long hike with my friends this year, I'll probably grab the FitBit to see what the daily mileage looked like.  If I can find it and was prepared enough to charge it. But it'll be because I'm choosing to move and curious to know how much.  If I need a day on the couch... which doesn't happen that often... I'm going to embrace it instead of feeling bad about it.  And maybe the sun will come back out in Seattle, and I'll chose to go for a run.  Or go kayaking... because I love that far more.

As always... if you have a FitBit or other kind of tracker... you should use it how you like.  You do you.  I'll do me.  

SUGAR!

It was recently recommended to me that I watch the movie “That Sugar Film” which also has a book, "That Sugar Book" which I also read.  I’ve spent many periods in my life avoiding sugar or carbohydrates or dairy. I always feel better without these things in my diet, but tend to have a backlash after they find their way back into my meals. I'm not currently restricting anything, but I always like to learn about nutrition to make more informed choices about what I'm eating, so I figured I'd check them out.  I've previously written about nutrition here and with the Whole 30 here. I'm DEFINITELY NOT recommending anyone restrict sugar or try these diets - but if you're interested in learning the science behind how sugars interact with your body, these are entertaining and eye-opening resources you can check out.  I've spoiled the story a little bit here, but the details and imagery were worth it if the topic interests you.

Australian movie actor and writer Damon Gameau met a girl and took refined sugar out of his diet to get healthier... plus that's how she ate and cooked.  He later decided to do a self experiment eating the average daily sugar intake for 60 days to see how his body reacted. He filmed the experience - making the movie- and kept a diary which he then used to write the book.  In summary, the addition of 40 teaspoons of sugar (about 160 grams per day) made him sick, but here are some of the highlights.  

• If you removed all the items containing sugar from a supermarket, only 20% of items would remain.  That's because it's added to pretty much all processed foods.  
• In the 1970's, there was a sugar versus fat battle around the world and ultimately it was decided to remove fats from the diet, resulting in a sugar boom. Low fat everything became available, but to make better flavor once fat was removed, sugar was needed.  It was suggested throughout both of these resources that the negative outlook towards fat was created by the sugar industry.  This ultimately led to massive creation of fad diets, like the Atkins diet, which believed the opposite was true and restricted sugar and carbohydrates instead.
• One teaspoon of sugar is roughly 4 grams.  So you can figure out by looking at nutrition labels how many teaspoons of sugar you're consuming based on the grams listed. 
• Sugar has a long list of alternative names on labels which sometimes make it easier for manufacturing companies to hide it.  Fruit juice concentrate = sugar.  High fructose corn syrup = sugar.  Agave = sugar.  Nutrition labels list ingredients in order from highest content in the product to lowest.  By using a variety of these (and fake sugars like maltodextrin), the concentration of each one is lowered so the ingredient gets bumped later in the list.  Tricky.

So the narrator, who has been off sugar, starts consuming sugar with a team of supporters including physicians and dieticians to watch his blood levels, body weight, and nutrition. He does this challenge without touching any candy, baked goods, soda, or chocolate.  He only consumes foods marked as healthy like yogurt, cereal bars, and juice and chooses low fat options whenever possible. He gets blood markers taken before, during, and after the experiment monitoring for changes of the heart and liver as well as tracking his blood pressure and heart rate. 

Different types of sugar are explored in these resources and the basic science of how the body processes sugars is outlined.  For example, glucose is the sugar that is used by the brain, cells, and organs for energy.  Lactose is the sugar that is found in dairy product. Sucrose is table sugar that is added to numerous foods we easily have access to.  It is composed of two different sugars - half glucose (the one I just mentioned is used as energy by the body) and half fructose. Fructose is the sugar in fruit and vegetables, including from corn as high fructose corn syrup and was previously very rare as fruit was not available year-round and to acquire honey, you'd have to fight the bees.  Fructose makes food very sweet, and it is considered to be the problem sugar because we have made it so much more readily accessible.

So Damon starts his sixty day journey of 40 tsp of sugar that are primarily fructose and sucrose.  He maintained his same exercise routine and overall had a consistent caloric intake from his non-sugar diet.  Some people he met along the way would say that his experimental diet looked healthier than their own typical diet.  Based on his study - that's a problem.  

It was obscenely easy to hit the target of 40 tsp per day. Cereal with yogurt and apple juice for breakfast on the first day totaled 20g (5 tsp) at breakfast. A 12 oz glass of apple juice has 33g of sugar (about 8 tsp).  Serving sizes really mattered because usually packages were multiple servings and could be far more sugar than he expected.  He noted many times throughout the experiment that beverages were a huge source of sugar intake and how this could impact your health in a variety of ways. 

After 12 days, he went to get a check up.  He had gained 3.2 kg (7 pounds!) and it was all in his belly. Visceral fat around the organs rather than distributed around his body.  Three weeks in, watching the movie, he looked ill. His blood tests showed changes in his liver enzymes with fatty infiltration.  He was feeling moody, lethargic, and like an addict waiting on his next sugar dose.  Twenty one days of sugar and it was obvious that it was making him sick.

One area that I found really interesting was that he explored the history of the aborigines and their health changes as they started eating processed foods and sugars.  He went to visit a community that had eliminated coca cola and the health of the community dramatically improved. 

One experiment he tried was to swap out the sugary food choices for a non-sugary option and add the actual amount of sugar to the plate.  This had a dramatic visual effect.  AKA it looked really disgusting. For example, he had planned to eat some teriyaki chicken where the sauce packaging said it had the equivalent of 4 tsp of sugar in it. Instead he had chicken without sauce on it and poured 4 tsp of sugar over the chicken and consumed that. Instead of drinking a bottle of Powerade that had 8 tsp of sugar, he drank warm water with 8 tsp of sugar. Ultimately he still had the 40 tsp for the day but as straight up white table sugar. This made him throw up. 

A month into the experiment, Damon comes to America. (side note: if you haven't seen the movie Coming to America, you MUST!  Here's the trailer.)

Upon his arrival to the USA, he gets a Jamba juice that has 34 tsp (136 grams) of sugar in it. He then shows all the fruit he would have had to consume to make that smoothie and shows how it would be impossible to eat that many whole pieces of fruit.  I've never tried to eat four apples in one sitting... but I definitely don't think I could...and then throw in a banana and some berries and limes?  No way!

He realized quickly it would be super difficult to stay under 40 tsp sugar per day because of all the high fructose corn syrup in the USA, which is not produced in Australia. He meets with an Appalachian region of Kentucky dentist who does mobile home treatments educating kids on how much sugar and caffeine are in Mountain Dew and Pepsi (or Coke). They have considerable tooth decay and start drinking soda at age 2-3 out of their baby bottles! An almost 18-year old has a mouth full of rotten teeth and they plan to extract many of them on the movie.  Damon reached out to Pepsi who said, "In moderation, Mountain Dew is part of a balanced healthy diet." 

He meets with researchers and undergoes various tests. One test was to get his brain studied under fMRI so while sugar is fed to him, they monitor the effects in the brain and then they teach him the science of sugar on the brain and hormones. He also can see what happens to his brain when he is simply shown a picture of a milkshake.  After having so much sugar, even the image of a sugar intake lit up his brain like a Christmas tree.  The researches told him about a study that showed rats worked harder for sugar than for cocaine... it's that addictive!

At the end of 60 days, Damon completes the journey and goes for follow up tests. I won't go into the details... but all of them were bad.  He had a body weight increase of 8.5 kg (18.7 pounds), 7 percent body fat increase and 10 cm increase at waistline.  And the whole time he's eating foods marketed as  "healthy." The calorie intake was virtually the same, but the source of the calories was the problem. 

Then he goes through the change back to his healthy diet. The first week he felt withdrawals and horrible sleep.  It took almost a month to get over the addiction/cravings.  He quickly lost 6 kg just by changing back his diet. Blood tests also restored. Good news: this is a reversible problem! The palate took a while to readjust, but overwhelmingly his body recovered (in the short term).

The recommendations from the movie and book are to limit to 6 tsp of sugar per day which is 24 grams.  Some people are more sensitive and should restrict to less because it triggers them, others can probably tolerate more.  According to the book, in 2003, the World Health Organization was preparing to recommend limits of 10% of caloric intake be from sugar. The sugar industry attacked the WHO and threatened congressional acts that would pull $260 million in funding if they did it. That recommendation was never made public, which suggests that the government and politics interfere with health policies... isn't that sweet?

Happy 2019, everyone.  Stay healthy.

2018 Year in Review

The last blog post of 2018! Since I started writing in November 2017, Abby's World has had 14,000 visitors.  I still don't like the title... Some posts were really popular... four posts had over 400 readers, others had less interest... and that's ok.  I think it's safe to say that I'm still figuring things out a bit to narrow down the scope, but I'm enjoying the variety of topics right now.  Thank you, so much, to everyone who has stopped by! I hope you've learned something and that I've been helpful to you in some way.

Today's post will serve as recap of 2018 - both personally and professionally - and a look back at some of my favorite posts of 2018.  As for 2019, I don't think I'm going to write a plan or set goals - other than to keep writing.

The Seattle Storm and UConn Connection

My 2018 biggest moments:
I'll start with the Seattle Storm winning the WNBA Championship, which I wrote about here.  I was so fortunate to be able to attend WNBA Finals Game 3 in Washington, D.C. with my brother, and still love basketball despite my poor skills at playing the game. I'm already looking forward to next season and it's still several months away.

Dear Evan Hansen, New York City, July 2018

As great as the championship was, my family celebrated a huge milestone this year.  In May, my niece and nephew became B'nai Mitzvah, which is a Jewish coming-of-age or right of passage.  They're thirteen years old, now!  The actual events for the B'Nai Mitzvah were incredible and I'm so proud of them for their accomplishment and hard work, but more special was the opportunity to celebrate them each in their own individual way.  I asked them a few months before-hand what they would want most, and I love how different they are and what they chose.  I celebrated my niece by taking her, my sister, and my mom to see the musical Dear Evan Hansen in New York City.  If you haven't heard much about this story, I encourage you to check it out, particularly if you have teenagers in the house. I'm so glad we could do that together, and that it was what she wanted to do - with her aunt, mom, and grandma.  I celebrated my nephew at the Denver Broncos versus Seattle Seahawks game in Denver, CO.  He's been a Broncos fan since birth because he liked the color orange and had always wanted to see their stadium.  As a sports fan myself, I really loved watching him experience something he had wanted to so much... and the rivalry of rooting for opposite teams but in a mature manner.  It was a chance to spend time with my favorite people as they head into teenage-hood and, soon, adulthood.  Next year they'll both attend Cheshire High School, the same school I graduated from fifteen years ago.  I remember holding them when they were born and all of these events were a flood of pride and emotions.   Because of them, I spent more quality time with my family in 2018 than I had since I moved to Seattle.  That was the best part of 2018.

Seattle Seahawks @ Denver Broncos, September 2018

Some of my other favorite things from 2018 that have nothing to do with Physical Therapy:
I saw the Goo Goo Dolls perform their 20th Anniversary celebration of Dizzy Up The Girls.
I rode in a helicopter for the first time. Total trip time was about 3 minutes.  It was awesome.
I read the first five books of the Harry Potter Series and watched the first three movies... my first time for all of that.  Don't worry, book six is in progress and I'll finish all of it in 2019.
I read a lot of books in 2018, actually.  Some really deep, sciency stuff.  Some much lighter and more relaxing.  I have come to embrace the audio book for commutes. I read The Origin of Species which I wrote about here and definitely do not recommend others read, but feel like I can read anything if I could get through that.
I got addicted to yoga.  And then dropped out of yoga.  I miss yoga.

My 2018 Physical Therapy Continuing Education was primarily focused on three areas.
1) Orthopedics from Mike Reinold, Lenny Macrina, and Eric Cressey.  I took Mike's shoulder seminar, which I wrote about here, Lenny's knee seminar which I wrote about here (and his elbow course), and Eric's shoulder course which I wrote about here.  I'm so grateful that there are mentors willing to share their expertise and knowledge online, and who also have made trips out to the West Coast for me to learn from in person.

2) Chronic Pain, primarily from Lorimer Moseley and Adriaan Louw.  I've written about those experiences here - from reading Explain Pain, and here from reading Explain Pain Supercharged and from meeting Lorimer Moseley at his presentation at the University of Washington.  Starting in two weeks, I'll be working with the Seattle Children's Pain Clinic as part of a collaborative team to help kids experiencing chronic pain.  I'm looking forward to putting all that learning to good use.

3) Strength and Conditioning.  I passed the CSCS (Certified Strength and Conditioning Specialist) exam in 2018, which I wrote about here and took a Medbridge Education Course instructed by Sue Falsone on this topic as well.  This has definitely made an impact on how I treat patients, specifically by loading them more and manipulating rep/set schemes a little bit more than I did in the past.  A few PTs have asked me if I thought this process was worth it, and for my patient population and side gigs, I feel that it is definitely useful.  I work in Pediatric Sports Medicine so my patient population is mostly athletic and getting back to sports.  They've generally never worked with a strength and conditioning coach or a physical therapist and don't understand any of the key basics of movement or how the body works.  I love having this background knowledge to educate them!

I feel like I spent a lot of time working towards growing as a physical therapist in 2018, but when I look back, it wasn't even close to what was most important.

Looking forward to 2019:  I'd be lying if I pretended that 2018 was perfect. Social media sometimes has that impact...  nobody posts their tears and struggles on Facebook and Instagram.  I certainly only post the happy times and the beauty I see around me. In truth, 2018 was a hard year.  I'm not sure 2019 will be easier... but there will be more family time and more hard work and growth.  And for all that, I'm grateful.

Happy New Year!

Anatomy Semantics

I got an email from someone who has recently gotten into a regular workout routine, trying to get into better shape with some weight loss and increased strength.  He was wondering if I would look at the program he's been using for a while and make some recommendations on how it could be improved for better gains.  The program was made from snippets he put together from men's health magazine.  So we set up a phone call to go through the program.  I've previously written a little bit about strength training in this post, entitled "What do physical therapists do? We Strength Train."

Biceps - Two Muscle Bellies 

The strengths of the program he already had going were three:
1) He was regularly participating in exercise and the workouts were planned and programmed with ways he could progress them.  In my opinion, the best training program is one you will do consistently.  But once you've got consistency down... all programs are not created equal.
2) Pretty much all the body parts were covered in some way.
3) He had learned to squat and deadlift.  Though we've previously worked on his form via Skype when he was having some pain doing it.  I had him using a broom in his house to hip hinge and weight shift and change his set up and we had a blast doing that probably two years ago.

The key weaknesses that I noticed were:
1) The program was separated out into six different days: arms, shoulders, chest, back, legs, and core.  He spent 1 hour focusing on that body region when he did that training day, and he strength trains about 3 times per week.  Because of that, each body region was only getting targeted twice per month - and that was only if no days were missed due to scheduling complications.
2) There were several single muscle exercises including wrist curls and wrist extensions or hamstring curls that would be fine for some training goals, but really didn't optimize him reaching the goals he stated.  In my opinion, these take up time and energy from bigger bang-for-your-buck activities.  They have a place - and I use them with patients sometimes - but in general I'm team multi-joint exercise.

Triceps: Three Muscle Bellies

3) There were no single leg activities.  I use single leg exercises a lot with patients and have also written about the seven key movements a la John Rusin here. squat, deadlift, lunge, upper body push, upper body pull, and carries.  One of those key movement patterns is the lunge... and this program didn't include those. I really like single leg activities because it gives you a chance to work on balance which also incorporates the core and because it changes the stability demands that aren't present with a double leg exercise.  Also, life requires us to operate on one leg fairly often - going up/down stairs, walking, a curb, getting in/out of the car, playing sports... it's functional to train on one leg.  And when I mentioned this, he noted that he didn't like single leg exercises because of poor balance... soooo obvious solution.
4) It was a very high volume program... three sets of 15 for each of five different exercises that he then repeated a second time through.  He probably got some cardiovascular system development from this scheme, and maybe even some muscle toning, but felt that he wasn't making considerable strength gains, which makes sense.  With a volume like that, you're not recruiting enough muscle fibers.

Since he has no background in strength training or anatomy, we discussed some of the key concepts of training.  Ideas like the three planes of the body, push versus pull, horizontal versus vertical actions, pairing exercises a little more purposefully to either alternate body parts: like a bicep curl to a triceps extension or to overload the same one in different ways.  And then he said - "Oh ya, I've been meaning to ask you about that.  I recently was thinking about muscles while working out and wanted to know more about the semantics of the names biceps, triceps, and quadriceps. Bi = 2, tri = 3, quad = 4... of what?!" This was the moment. 

Quadriceps: Four Muscle Bellies

This was the moment when I realized that there have to be loads of people who go through life never studying anatomy or how the body works.  Working in pediatrics, I generally assume my patient population has not yet learned about anatomy.  Most haven't. Some know a little from playing sports.  But I've taken at least seven anatomy classes in my life and didn't think it was possible for an adult to have gone through all of their schooling (he has a bachelor's and two master's degrees!) without ever taking anatomy. I don't know how to write computer code or how to wire a light fixture or fix a leaky sink... why should I expect that everyone understands basic anatomy?  We're all capable of learning these things... but we don't all know them.  Talk about being a bit close-minded!

This was the moment I realized how much education it takes to be a physical therapist.  This is the moment I gained new appreciation for how people can really hurt themselves when they don't know enough about the human body and try to load it - whether intentionally through training, or unintentionally overloading through sporting activities or daily activities that their body isn't prepared for.  This was the moment when I realized that personal trainers, strength coaches, physical therapists, and anyone else suggesting exercises to clients or patients needs to understand how the body works and the concepts that the clients should understand to be more independent in helping themselves.

And so I taught him about the difference between the biceps, the triceps, and the quadriceps.  The body actually has two different biceps muscles - the biceps brachii in the arm and the biceps femoris in the back of the thigh. "Ceps" comes from the latin word caput which means head, and so each of these muscles has multiple heads.  The biceps of the arm has two heads - also often referred to as muscle bellies.  The triceps on the back of the arm has three muscle heads.  And the quadriceps of the front of the thigh has four muscle bellies.  I had to send him pictures to show what I was talking about because just saying the words was meaningless.  These muscle clusters are named as a group because they work together to elicit the same action. For example, the quadriceps, as a group, straighten the knee.

Combine the new basic knowledge of what a muscle looks like with those key concepts we already discussed such as the three planes the body can move in - front to back, side to side, and a rotational plane and how muscles work in certain directions and how important it is to consider all the directions for a well-rounded program.  We discussed some of the basics of muscle growth - and how there are muscle fibers that are more meant for endurance like high repetitions - which is what he had mostly been doing, but also muscle fibers that focus on strength and need to be more overloaded with heavier weight to use those, which had been missing in his routine.

I really enjoyed this conversation because it opened my eyes to the reality of the world... how could I have thought so many people understood these concepts which just come so much more naturally to me!?  I can't wait to take the opportunity to help more people better understand how their body works.  I also enjoyed the opportunity to educate someone so they can make changes to their workout program and develop a plan that could be more effective, and that they can modify independently.  I'm not an expert in training programs, but now he has three options of workouts and can hit each body region at least four times per month, he has a better understanding of how to change reps/sets and that there's a reason to choose these, that he probably was under loading himself, and that above all else, he has found the number one key to training: consistency.  Just by training regularly and making it part of his weekly routine, he's already miles ahead of everyone on the couch.

Can't wait to see what kind of results he gets!

Becoming a Clinical Instructor

UConn PT at the Golden Gate Bridge, (Thanks, EL!)

It's finally happened.  The University of Connecticut Department of Physical Therapy must have experienced a temporary moment of insanity because they're sending me a student!  A moldable young mind on her path to becoming a physical therapist with aspirations of working in pediatric orthopedics... and since I was willing to take her, they found a way to get a contract with Seattle Children's Hospital.

Connecticut is a small state with five PT schools, so pretty much all of my classmates had to do at least one rotation out of state because there aren't enough spots for everyone to stay close to home for all those students.  And if you have specific interests like pediatrics, your options are even less.  It provided for opportunities to learn about different cultures around the country and different methods and random meet ups with classmates.  I had two rotations in Connecticut, one in Albuquerque, NM, and one in Denver, CO... and my classmates went to New Hampshire, Massachusetts, Arizona, Florida, California, Texas, Utah, New York... and maybe even more places I can't remember! 

I'm super excited to mentor a student. It feels like a way to give back to my alma mater while also having the opportunity to learn from someone who's reading current research and will have their own perspectives on optimal patient care.  I recently read a post in a Physical Therapy Facebook Group from someone about to take their first student and they were looking for advice in how to prepare.  I've also been asking around and reflecting on my own clinical experiences and instructors. I can easily think of some things that went well for me and others that weren't so great.

So, in preparation for her arrival, here are four things I'm hoping to focus on to help her have the best clinical experience possible... and then after she's all done, we can come back and see how it went!

1) Feedback:

I personally don't take feedback well.  Positive or negative.  I don't really like having much praise and I don't like hearing what I did poorly. On one of my clinical rotations, my CI gave me feedback in front of a patient that didn't sit well with me, and when we discussed it later on, privately, I burst into tears. (One of the comments on the Facebook Group was to prepare for tears because a lot students cry from the stress... but I'm not so sure). Talk about a moment severely lacking in professionalism! Embarrassing. As such, I am very aware of the importance of private feedback - unless there is a safety issue.  But being aware of that importance and being able to save feedback until a later time doesn't always occur.

Part of being a clinical instructor is helping a student develop their clinical thought processes for how they evaluate and treat patients.  Feedback is a necessary component of that, and sometimes has to be done in front of the patient - but it can be done in a right way that doesn't scare the student or patient.  From what I've observed by coworkers who have had students, there is definitely an art form to being a good clinical instructor. 

And the feedback goes both ways!  Taking a student gives me more opportunities to have my methods questioned and receive feedback about how I interact with patients and find new ways to improve my own skills. This article discusses bi-directional feedback and explains how when both the student and instructor give feedback to one another, the experience is optimized for both people and there is enhanced learning. How to give the feedback is of course an important consideration.  And when.  Because providing feedback too quickly limits opportunities for students to make mistakes.  And people tend to learn best from their mistakes... as long as the patients aren't going to get hurt.

2) Communication: 

Obviously this aligns with feedback, but deserves its own space.  With my own clinical rotations, I didn't feel like I learned most from treating the patients.  I learned far more from discussing why I chose the interventions I used, studying about techniques or conditions I was unfamiliar with, observing interactions between providers and patients, and trying different things.  Fortunately, I'm a talker, so discussing cases and thought processes came fairly easy to me. Conversely, listening is the bigger challenge for me.  I'm hoping that being an instructor will help me work on my active listening skills, particularly not interrupting mid-conversation.

UConn PT at the Grand Canyon

Communication also includes outlining expectations.  This includes small things like the schedule we'll follow and how to address patients and parents up to more critical considerations such as the sufficient knowledge for patient care.  Preparing for weekly follow up sessions to discuss progress and goals for the upcoming week was essential for my success.  Scheduled meetings are useful, in my opinion, to regularly check in, develop goals, refer back to expectations, and measure progress. I like organization and efficiency, so my instructor who was not very efficient was more challenging to learn from than the more organized CIs.

Also, as I've now had a few PT jobs and seen numerous ways to "skin a cat", I'm becoming more comfortable with the fact that physical therapists can treat differently and still be impactful.  There are exercises or techniques I don't use or I don't like... for whatever reason... but that doesn't mean others can't use them if their reasoning makes sense.  Sometimes I share patients with a coworker and we do things in very different ways... but as long as the patient continues to get better, I have to be willing to recognize that there are multiple roads to recovery.  

3) Practicing skills:

One of the best pieces of advice I got from a clinical instructor was to find a system that I could do well to use for evaluating patients as a starting point.  I could vary from that system as I got more and more comfortable, but I had to have a fall-back in case the patient didn't progress the way I would expect them to.  For me, that system was the SFMA, Selective Functional Movement Assessment, and I still sometimes fall back onto it (or parts of it) now! I wrote about that experience here.  I practiced the assessment on my roommates and on my clinical instructor and read the book on how it worked and also used it on a large number of patients.  Then, towards the end of my rotation, I was able to evaluate patients without using the SFMA, unless I wasn't sure what was going on, and then easily went back to what I felt I was good at.

In addition to evaluation techniques, in the pediatric population I don't find myself using a lot of manual therapy - but there are certain times when I feel it is necessary.  When I was learning manual skills, I needed my instructor to do them to me and have me do the technique back to them.  This way, I could get feedback on my positioning and pressure, but I would also need to use it fairly soon in order to have any retention.  I know that we used down time to practice various special tests, but if I didn't end up needing them for a whole week, it was hard to recall that knowledge later on.  

4) Providing Resources:

One of the suggestions made on the Facebook post came from a student suggesting to provide a few articles that demonstrate some of the mindset and practices the instructor uses.  I found this interesting, because only one of my instructors gave me resources at the beginning of my affiliation and that was, without question, my best experience.  I have some ideas of articles that I've read that have been impactful to my practice, but I don't know that I feel a need to start off that way.  I'd rather see if we think similarly first and share them if we don't, I think... but in the month until she begins, I'm going to give this some extra thought.  

Key resources don't just include papers to read.  I work with a group of incredibly talented practitioners including my sports physical therapist team, but multiple other types of providers share our space.  There are opportunities with other types of rehab specialists as well as providers outside our space but within the company relevant to PT practice that will also help a student grow. Should my student have interests in learning about additional experiences, I'm hopeful that I will be able to help arrange those opportunities. 

Overall, I'm excited to learn as much as I am to teach.  Especially since I'm getting a Connecticut Husky.  I hope she brings a hoodie to take a picture of in front of the Space Needle!

"Long Term Cost of Quick Fixes"

Earlier this week, I attended the Seattle Pediatric Sports Medicine quarterly symposium entitled "Long Term Costs of Quick Fixes." I've previously written about that group with regard to their ACL Injury Prevention program here and here. This symposium was a panel of 4 elite athletes discussing their careers and injuries and some of their interactions with healthcare providers.  It made me think of all the sports movies, like Varsity Blues, with scenes of an injured athlete with a needle about to enter their body to get them back on the field right away. For me, the highlight was seeing Seattle Storm co-owner and Rowing Olympian Ginny Gilder! It's always fun attending networking and educational events and learning of the connections between people you know and the people you meet.

Ginny Gilder, Kerry Carter, Seth Orza, and Peter Shmock

Here's a little bit about each of the elite athletes who were included along with some insight to injuries they sustained and some quotes they said which stood out to me.

1) Ginny Gilder -  An Olympic Silver Medalist in Rowing in the 1984 Summer Olympics and also qualified for the 1980 games that were boycotted.  She attended Yale University, has launched multiple companies, all civic-minding and many empowering young women.  She is currently one of the owners of the Seattle Storm - so I was super excited to run into her, and she wrote a book called Course Correction: A Story of Rowing and Resilience in the Wake of Title IX reviewed as "Wild meets Boys in the Boat, a memoir about the quest for Olympic gold and the triumph of love over fear."  Guess what's now on the top of my reading list for 2019!?!

Injuries: Ginny told about her experience breaking a rib and having a cortisone injection to the intercostals to calm things down and being told by the physician to take some time off from rowing, only to be on the Charles River in Boston on a beautiful sunny day and knowing she just had to be on the water, getting into her boat for a casual row, and ultimately feeling a pop in her ribs that she knew was because of not listening to the advice she had been given.   She also commented on back pain that has been chronic and requires continued care today.  The common theme throughout the presentation was that at the elite level, athletes do whatever it takes to compete, sometimes ignoring advice for the long term.

Quotes:
- "Young athletes depend on competent adults to make decisions for them.  As a parent, you may not know how to deal with your kids injuries.  Parents just don't have the knowledge/experience to make all these decisions."
- "Ask parents why they encourage their kids to do sports?  What role sport is playing in setting up their child for success."

The controversial Goldman's Dilemma was also referred to, though not by name.  This was a study done in the 1970's where athletes were asked if they had the option to take a drug that would promise them the highest level of success, would they take it even if they knew it would kill them in five years.  It was a component of the anti-doping legislation that would later come out because at that time, the surveyed athletes would frequently respond that they would take the drug for the success.  Later editions of the study found different results, but some of the commentary focuses on the differences of how an elite level athlete thinks and operates compared to the general population.

2) Kerry Carter - played fullback for the Seattle Seahawks in 2003-2004 and the Washington Redskins in 2006 as well as in the Canadian football league. (I didn't actually know that Canada had a professional football league!)  He currently works as the Vice President for Football Operations for a company called Atavus Rugby and Football - whose CEO is Karen Bryant, former President/CEO for the Seattle Storm.  Kerry's responsibilities at Atavus include teaching football coaches how to teach football players proper tackling and they use scientific metrics to try to prevent injuries.  When asked about the other sports he played, he said volleyball - which is a rare combination for a football player.

Injuries: Kerry described an ACL tear, a shoulder labrum tear, a shoulder AC joint injury, and others that were not as severe, but that he went through multiple surgeries and worked hard each time to get back to the field.  He also discussed some of his lingering aches from those past injuries, and could describe some of the tactics his teammates used including one who had a pharmacy in his locker and would pop tons of pills daily to be able to tolerate the rigors of football.

Quote: "The thing I wish I knew when I was hurt was if there were other options available.  But to be honest, I may not have chosen any alternative that would have taken me longer to get back on the field."

3) Seth Orza - a principal ballerina for Pacific Northwest Ballet and a 20-year professional dancer.  Seth discussed that he also runs and conditions and lifts weights in addition to a 90 minute daily warm-up routine with the dance company and about six hours of rehearsals per day.

Injury: Multiple episodes of back pain.  He said "my back exploded at age 14" and he actually didn't receive healthcare for it, though he's not entirely sure why.  He spent some time in bed and then was able to return.  Since that time he has had additional back injuries and multiple PRP treatments to his knees, and he gave considerable credit to his PT, (my former coworker) Boyd Bender.

Quote:When discussing elite level sport or performing arts: "You're going to get injured, but it's a matter of how you deal with it, who you trust and surround yourself with, and whose advice you take to get through it."

What struck me with Seth's input was the words he used to describe his back injury - because this has come up in presentations that focus on the biopsychosocial model and how much impact words have.  Seth is in his mid 30's and the imagery of his back exploding at age 14 has been reinforced into him for 20 years... but maybe it doesn't impact him!

4) Peter Shmock - An Olympian Shot-Putter who competed in the 1976 games and also qualified for the boycotted 1980 games and now works in Seattle as a high performance coach.  In the late 1990's, he was the weight training coach for the Seattle Mariners and Pacific Northwest Ballet and has trained a long list of elite-level athletes.

Injuries:  Peter was the only one of the group who reported that he hadn't had any major injuries because of the innovation of legendary track and field coach at the University of Oregon and for the USA team, Bill Bowerman, who believed in recovery and a more holistic approach.  If his body didn't feel right, his training or competing was modified and he felt this was essential to his performance.

Quotes:
- In consideration for those he trains - "What is enough for you today?"
- In consideration for athletes who tell him they think they need to just keep doing more, rather than modify their training - "Do you want to do mindless work? Or do you want to improve?"
- "Train or rehab with intent and at a sustainable rate."
- "Be an advocate for the kid you're working with.  The problem with parents/coaches is that they often don't know how to advocate.  They only know go hard or go home."

As a healthcare provider for children and young athletes as well as for elite athletes, I took many important pieces from this presentation and had a great time.  Looking forward to seeing what the group puts together in 2019!

Words My Mom Doesn't Want Me To Use

Many Words of Mental Health

This post is long overdue.  So are many, many others that are similar that I've half-written but are not completed and haven't published because I hate dealing with my own vulnerabilities and weaknesses. That's right.  Hate.  A word my mother banned me from using as a kid because it is so intense.  I remember her telling me that if you use the word hate regarding another person, you mean that you want them dead.  I'm sure I probably had used it towards my twin brother for hitting me... and ultimately I got in trouble for using a bad word rather than him getting in trouble for physical violence.  Of course I didn't want him dead... just to quit it with the wet willies. So hate is an intense word and I don't take that lightly. But it's appropriate right now.  The alternative would be saying that I can't do it... I'm unable... but that portrays weakness... and I'm perfect so I won't use that word.

Perhaps you've heard of the author Brene Brown.  I may have mentioned her in a past post, but honestly I can't remember.  She has written several books on various topics including, according to her website, "courage, vulnerability, shame, and empathy."  She has this quote on her home page: "I believe that you have to walk through vulnerability to get to courage, therefore...embrace the suck."  Ha! Suck is another word my mom wouldn't let us use as kids... funny how both of those words came up and a blog post was born.  I hate facing my own vulnerability so much that I was incapable of reading Brene Brown's book, Daring Greatly.  I tried. Multiple times.  I checked it out of the library, read the first chapter over and over again because I couldn't process it, and when I got the notice that it was due, I returned it.  My roommate really liked it and others by this author, and usually I agree with her taste in books, so I watched her Ted Talk on YouTube - which was OK... or tolerable - and checked the book out again.  Couldn't read it.  Physically incapable.  So I returned it and tried the audio book, but I never made it past her discussions of vulnerability.  It's dangerous to black out while you're driving but I felt like I tuned out the book and the whole world.  Specifically regarding Daring Greatly... and a few blog posts.... I can't walk through my vulnerability to get to the courage.  I'm a coward. Maybe I'll try to Dare Greatly again in 2019.

I've been writing this blog for many reasons... all of them selfish.  I'm not writing for you... I'm writing for me.  While I'm glad others are reading it, I don't actually care when a post only has 20 readers versus the more popular ones that have hundreds of views.  Oh!  There's another phrase I drove my mom crazy with as a kid... "I don't care."  She'd ask what I wanted for dinner... this was probably around 7th grade... and I'd say I didn't care.  But that's when I was trying to stop eating red meat so when meatballs or lamb chops showed up on my plate... I absolutely did care!  So many life lessons... thanks, mom!

Mom

Selfish or not - I'm hopeful that something I say helps other people.  I'm hoping some young physical therapists check out some of the continuing education courses I'm doing or some PT students learn from the mistakes I made earlier in my career. It would be awesome if suggestions I make help decrease some injuries in youth athletes or help people cope with their chronic pain.  When those more vulnerable posts do finally sneak onto the published side of the blog, I absolutely hope someone benefits from them... but I'm getting out what I'm putting in.  I won't pretend I'm doing this to be generous.  This blog has a much bigger purpose that has not yet reached full transparency.  Yet.

So why today's blog post?  A friend is in pain. Maybe not the physical pain that I treat in the clinic or chronic pain that I've written about so many times on this blog.  I'm not sure.   But there is suffering.  Sadness.  Emotion.  I got a phone call today and was told that they had decided to self-admit for inpatient mental health services a few days ago.  Only a very small number of people know and for some reason, I'm on the short list.  They wanted to know what I thought.  Talk about vulnerability.  Courage.  Strength. 

I think that others may be struggling who might need to hear this too. To be honest... when I'm having a down day... I need to hear these things myself.  Despite all my jokes, laughter, and smiles... I do have down days.  So here's what I think, and also some of what I told my friend.  And I'm sharing with whoever reads this... because it's the start of facing my own vulnerabilities.

1) Mental Health, per dictionary.com, is a) psychological well-being and satisfactory adjustment to society and to the ordinary demands of life; b) the field of medicine concerned with the maintenance or achievement of such well-being and adjustment.  Wikipedia says it's the absence of mental illness.  EVERYONE has a mental health status. And it isn't some concrete place that you're always going to be in. It's a fluid construct. There are times in life that are more stressful or more sad or overwhelmingly happy...  and your psychological well-being changes during those times. That doesn't make it pathological - or mental health illness.  But just by looking at someone - you really can't tell if a person has a pathological mental health or not.  Just like you can't tell I'm Jewish by looking at me... there's no sign on my forehead telling you these things you can't see.

Remember Robbin Williams?  He was a comedian and all around funny dude... and all you ever saw publicly as a fan of his movies was happy, jovial, doing voices Mrs. Doubtfire or Genie from Aladdin.  But underneath the skin was a dark place that most people couldn't have known about.  I refuse to believe he was sad all the time on the inside while happy all the time on the outside.  But I have no way of knowing.  And so - everyone has a mental health status - but more importantly - you never know what's going on with other people under the surface unless you ASK.

2) They are not alone.  I don't know what specific mental health circumstances my friend is going through. It's none of my business if they don't want to tell me.  I can be a supportive friend without details. Maybe other people react differently? What I do know from recent reading about mental health illnesses is that there are a long list of them - potentially including: anxiety, mood disorders, depression, body dysmorphia, PTSD, eating disorders, personality traits, social anxiety, diagnoses like schizophrenia or bipolar disorder, gender and sexuality issues... and TONS of people experience these problems. Unfortunately, this friend isn't the only person I know having some struggles right now.  The people I love are hurting... which hurts me, too. And so I told my friend about my own recent mental health journey and we couldn't understand why neither of us had discussed these things before now. Well... actually I don't talk about it because of that V word I talked about above... you know the one. Maybe that happens for a lot of people?

3) There's a lot of darkness going on in the world right now.  The news is sad. You can't go on social media without seeing really big issues - global warming, separation of children at the border, economic policy, gun control, starving countries, natural disasters.  All those big issues can make an individual feel pretty small and less important. But less important is NOT unimportant.  The holidays are coming up.  I'm personally looking forward to seeing more photos of children looking at Christmas Trees and Menorahs, families having meals together, and drowning out some of the bigger stuff.  Let's bring it all a little smaller, find ourselves a little bit, take a deep breath, and focus on the positives and things we can control.  Even if it's just for the month of December.

I can promise there will be more where this came from.  If you feel there is a negative tone to this post, you should know that in my head there is only optimism.  hope.  healing.  and love.