The Battle Against Fat Continues

Let's kick of some 2023 blogging with a controversial topic, shall we?  The Battle Against Fat continues.  If you've never met me in person, you may not know that I am fat.  I don't say that in a derogatory or negative way.  It is simply a descriptor of my body.  I'm not really short or tall - average in height.  But I am apple-shaped and thus, fat is an accurate adjective to describe me. I don't choose to be fat. In fact, I spent my first 30 years yo-yo dieting in an effort to make myself smaller, having great successes followed by even greater reversals. With support from a therapist and a dietician, I've learned to accept that this is the body that I've got and overall it does it's job pretty well, even if it isn't the socially approved size. That doesn't mean I don't wish I was smaller - it just means I'm no longer torturing myself to try to achieve that and instead strive to live healthily. 

cartwheel

I've previously written a few posts about my own experience with binge eating disorder and recognize that this impacts my beliefs about weight loss and body size. I have endured plenty of weight stigma and fat shaming both personally and professionally. My body size has come up in conversation as a healthcare provider during hiring processes and I've received derogatory comments from colleagues.  

In Physical Therapy World, there are physical therapists who think we need to be thin, fit, and muscular to do the job we do... but the way I look is not an indicator of my level of fitness and it certainly has no relationship with how smart I am or how much I care about my patients.  Imagine if we had to be capable of performing all the things our patients and clients do?  I wish I could shoot a basketball as well as some of the basketball players I've been fortunate enough to work with. I treat dozens of gymnasts and have never been able to do a cartwheel... I don't think that's because I'm fat. It's because I'm terrified of landing flat on my face.

I have also been a patient with doctors telling me that losing weight would fix whatever problem I was in for. Problems which also occur in people whose body weight is in the normal range on the (horrible) Body Mass Index Scale. There are numerous articles about how bad the BMI scale is, including this one. It was NEVER intended to be used in the way that it is. I went to have a sleep study a few months ago and the physician kindly explained to me that the findings would not be as accurate if I did a home study because the equipment used at home can't accommodate higher BMI as well as the equipment in the hospital does.  I asked my doctor, "If I was skinny, which test would you have me do?"  He said "the home test," so that's what we did. I respected him for presenting the data around the differences and for placing the blame on the equipment rather than on my body, and for ultimately treating me the same way he would treat a smaller person. 

Often ignored in this conversation are the kids I work with who also have higher body weight who whisper that they're so glad they don't have to work with the skinny PTs because it makes them uncomfortable.  The ones who have cried because a previous medical provider blamed their pain on their body, or that they hate their own bodies and are self-harming or thinking about it.  In some ways, my body size has made several teens comfortable enough to tell me there was an issue for which I got them help. In the clinic, it crushes my soul when I'm working with pediatric patients whose parents call their own kids lazy or fat rather than encouraging them to be active and work towards health. Or that time I told a little girl that she was strong and she looked me dead in the eye and said "only boys can be strong, not girls."  Or the kids who come into the clinic and walk on the treadmill only to be excited by how many calories they're burning. Are we even teaching them the right things? Where does this messaging come from?! 

I have been asked numerous times from parents how to help their kids lose weight, and when I point out all the things their body is capable of doing as it currently exists, it's like I have a third eyeball. Follow that up with asking about nutrition at family meals or physically active habits the family shares and you would think I'm suggesting families should be surviving on raw broccoli and running marathons together.  The American Physical Therapy Association has a Position Statement indicating that it is within PT scope of practice to "screen for and provide information on diet and nutritional issues" in collaboration with a registered dietician. The problem with this is that there are conflicting views about weight and what "proper nutrition" is in the United States. If all the doctors are skinny, the fat patients will never be heard or given medical care. We have a serious problem, but I don't think we're fighting the right battle. Instead of the Battle Against Fat, we should be fighting The Battle Against Too Expensive Nutritious Foods, The Battle Against Unsafe Play Areas For Kids, The Battle Against Decreasing Recess and PE in Schools, The Battle Against Unaffordable Child Care and Housing, and so many other battles.  Instead, our healthcare system is again doubling down on the Battle Against Fat, but now they're doing it against children. 

On January 9, 2023, the American Academy of Pediatrics published a new "Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity." I really didn't want to share the link to the paper because it's downright awful, but I also think people should have the chance to read it and make their own conclusions about the contents, so here it is. It's really long.  It's hard to include clips of the guideline here, so I've only selected this one clip about Parental Obesity which is considered a strong predictor of pediatric obesity.  And yet we're targeting these interventions on the children. 

The goal of these Guidelines is to streamline clinical practice for kids who are fat.  There are numerous recommendations made, and perhaps they may have done the right thing in suggesting that more kids get screened for metabolic disorders, but all the recommendations are based on use of the BMI Scale, which was created by a mathematician studying white men to find averages - never intended for use in children or even to be applied at the Individual level. The Guideline even hints at this, mentioning that BMI is not the Gold Standard to assess body composition, but it is easy to use. 

To be very clear, I believe that this guideline will be harmful and do not support the recommendations, and I am fully aware that this goes beyond my scope of practice as a PT, but not beyond my understanding as a human. Two particular recommendations worry me above the rest. Depending on BMI, recommendation #11 indicates weight loss medications should be provided for kids over age 12 and recommendation #12 directs bariatric surgery for kids over age 13.  Teenage girls who haven't yet started menstruating and will undergo considerable body development over the subsequent several years should not be having surgical interventions to change their digestive systems. I'm shaking with disbelief typing these thoughts. I know I am not a researcher.  I know that I am not a surgeon who could conduct surgeries like this on kids, and I don't know which surgical methods they would even use. Nor am I a pharmacist who would be prescribing kids drugs which could be needed for their entire lives rather than focusing on so many alternative options. I'm constantly seeing teens in the clinic with body dysmorphia, body dysphoria, eating disorders or disordered eating, and low self esteem and there is already data indicating the severity of depression in teens.  How much worse can it get as we start to prioritize weight loss even more?

I've finally finished reading the Guideline in all of it's terror, but before I could finish, I helped facilitate discussions at an event through the University of Washington on January 19, 2023 on a similar topic.  The event was part of the University of Washington Center for Health Sciences Interprofessional Education Program where students work to increase engagement with different medical disciplines. Thirteen programs including nursing, dentistry, public health, pharmacy, and physical therapy require their students to select from a variety of topics for interdisciplinary discussions and there were about 100 students at this event discussing Weight Stigma in Clinical Care. 

Participants received two articles prior to the talk, which was led by Dr. Lisa Erlanger, a Family Medicine Physician in Seattle, and Dr. Erin Harrop, a Licensed Clinical Social Worker and Professor at the University of Denver. First, "Everything You Know About Obesity Is Wrong," a publication from The Huffington Post written by Michael Hobbs that exposed some really eye opening patient testimonials about the harms of healthcare providers participating in weight stigma practices.  The article begins by demonstrating the delay between science finding solutions and medicine implementing them: The story of sailors dying from scurvy, easily cured by eating citrus fruits, but that fruit wasn't provided as different (more cost effective) options were tried instead, resulting in more death. Startling statistics were included that try to paint the picture of how unlikely it is to maintain considerable weight loss.  How many children will need to be medicated in order for one child to achieve and maintain normal weight?  I don't think this type of study has been done yet.

The other article, "How and Why Weight Stigma Drives the Obesity 'Epidemic' and Harms Health," by Tomiyama et al, an opinion piece from BMC. When will physicians catch up to the studies that show that weight cycling is bad for health and that weight stigma is even worse!  It's like this quote from the movie Mean Girls, "I don't hate you because you're fat, you're fat because I hate you." (Also - that movie is somehow 19 years old!)

So the session began with didactic education including review of the statistics and memorable anecdotes from these articles and additional research, followed by discussions of case studies.  Students elected to participate in this discussion for a variety of reasons which they shared - concerns about their families, wanting to learn how to challenge fat bias, growing up overweight as a child and experiencing weight stigma, wanting to learn how to talk to patients or friends battling weight-related challenges, and more. 

Even as a facilitator, I learned new things.  For example, "fat" as a word is a descriptor of having adipose tissue, however the moral judgement applied to using the word has created a negative connotation. More recently, "fat" has been re-claimed by those who live in larger bodies in a similar way to how "queer" was reclaimed by the LGBTQ+ community and the associated attitude towards these words are evolving.  Previously considered as a slur, "fat" has been  reclaimed as an identifier and we need to move forward to increase awareness and reduce stigma. 

"Headless Fatty"

Diet culture was discussed. An overarching set of societal beliefs that confuses health with weight, healthcare providers contribute to diet culture and weight stigma constantly and in harmful ways.  Diet culture encourages weight loss and correlates this with improved health, but it wrongly accuses fat as the cause for other conditions. It also moralizes things like: healthy food vs unhealthy, standing vs sitting, good movement vs bad.  It perpetuates a weight normative approach with a focus on BMI and having an "ideal" body weight. Health-ism occurs, as well, where providers may be accepting of higher weight AS LONG AS there are no metabolic health concerns. A common representation of diet culture was also mentioned: The "Headless Fatty" - showing pictures of large bodies without a face, a common, dehumanizing weight stigmatizing behavior. 

How does diet culture show up in healthcare?  The most common scenarios I've come head to head with are surgery being denied due to higher BMI and inadequate equipment availability. Orthopedic surgeons are frequent flyers in weight stigma, opting to avoid surgeries because there may be higher risk of infection in larger body sizes or predicted outcomes being less than desirable, sometimes including required weight loss prior to intervention. It's a frequent occurrence that poorly fitting blood pressure cuffs are used on larger bodied patients, which elicits inaccurate readings.  Waiting rooms at clinics may not have chairs that can accommodate a larger bodied person. Sometimes tests have limitations so they're not conducted on patients, thus increasing their risk of illness due to equipment and lack of training.  I already mentioned my own experience with sleep testing at home.

The discussion at UW did touch on the new Clinical Practice Guidelines, which was timely.  There were some resources shared including a blog from Ragen Chastain who writes about why the guidelines are harmful here. She included mention of unlisted conflicts of interest for many of the authors for the Guideline, as well as the American Academy of Pediatrics, with financial incentive from the pharmaceutical company that makes weight loss medications. I just feel icky reading this, but agree with her that while the authors may have good intentions to improve pediatric health, they may also be misguided and lacked input from eating disorder specialists and mental health providers who could have helped improve the guidelines to make them safer. 

Healthcare providers - if you congratulate your patients for weight loss without asking them about the behaviors around their weight change, you could miss serious diagnoses.  Like cancer, or an eating disorder, or celiac disease, irritable bowel syndrome, heart failure, diabetes, or thyroid problems.  You may have good intentions, but plenty of people lose weight and do not gain health - or even feel poorly.  The underlying goal should be health - not small bodies. Think about how you define health?  I've previously written a blog post about the different types of health, but I think that we, as healthcare providers, often exert our own beliefs of health onto our patients rather than hearing what they find important.  Usually people defining health choose functional answers, like ability to do certain activities.  The common medical definition of health is "Freedom from disease," but if this is the case, most of us will have periods of episodic or constant non-healthy time.  I used to think health was a thin body, but at my smallest, my mental health was poor and I was restricting so many foods, I couldn't maintain that lifestyle.  My smallest was bigger than many people will ever be, and it didn't bring me any happiness because I was in a constant brain fog from hunger and distracted by constantly wanting my next meal.  My biggest size didn't necessarily make me feel good, either, but at least then, I was able to eat and focus on my work and the challenges I faced were different.  Regardless, I have been the same person at every size I've been.

I'm sure I could continue discussing this topic ad nauseum, but I think I'll stop here.  Here's to hoping the kids stay healthy and safe. And good on you, University of Washington, for finding a place for these more challenging conversations in your medical programs' curriculums.

APTA Delegate 101

With my new pal Jenny Jordan

I was watching Gilmore Girls re-runs one evening in November 2021 when an email notification popped up on my screen from Dr. Jenny Jordan, Physical Therapist, Professor in the Eastern Washington University PT Program, former Chief and current Delegate for APTA (American Physical Therapy Association) Washington, and - I would soon learn - incredible human being. Jenny's email asked if I would be willing to discuss an appointment to a one-year term as an Alternate Delegate representing APTA Washington.  

With my long-time pal, Maryclaire Capetta

I've been an APTA member since starting PT School in 2011, but despite how much money I've spent on membership, at the time of Jenny's message, I really couldn't explain what the APTA did. I joined as a student when it was compulsory, and I maintained membership because it discounted board certification and allowed me networking opportunities that I occasionally took advantage of.  Also, it felt like it was the right thing to do, supporting the leaders of my profession.  I knew that Delegates existed and that they worked on making changes that impact the physical therapy profession from a nation-wide perspective, but I had never given any thought to being a representative myself.  One of my Professors in PT School, Maryclaire Capetta, now a long-time friend, has been a Delegate in Connecticut for many years. She took me to a Delegation event at CSM in Chicago in 2012, which was my first glance at the politics of PT.  Over my eigght years attending PT Pub Night events living in Seattle, I've gotten to know several of our local Delegates including some who are good friends. All of this to say - I knew Delegates existed.  I did not know how they came to be in their role, what they did, or why I would ever want to be one.

We set up a time to chat and Jenny explained the responsibilities and the time commitment and asked if I wanted to join for a one-year term. Washington had enough elected Delegates to serve two-year terms, but because our group is pretty large, if the time came to vote and someone wasn't available, we needed to have alternates to step in. Our Alternate Delegates participate in all the regular meetings along with the rest of the Delegation and contribute to the discussions and can work on developing policies, but they do not have the ability to vote unless an elected Delegate is unavailable.  The usual process to be chosen for the Alternate Delegate spots is to be the next highest vote getter on the ballot after the votes are counted. Unfortunately, there weren't enough names on the ballot for the 2022 cycle to fill the Alternate slots. I said yes, and after one year of a much deeper dive into what the APTA does, how new policies are formed, and learning about the problems the Association and the Profession faces, I'm here to share some of that with you.

First and foremost, I want to be very clear: I’m really new at this and there are many others who have been working in leadership roles for far longer who know much more about the APTA.  I was just recently elected into a two-year term as a Delegate for the 2023 and 2024 House of Delegates Cycles and have only attended one House of Delegates meeting so far. This is my understanding of things and my experience- it’s true to the best of my knowledge.  If I'm wrong, for sure someone should tell me!  

Let’s talk about Delegations first.

I've come to understand the Delegation to be a little like the US Congress, but instead of two separate chambers, ours are combined.  In US politics, there’s the Senate with two Senators from each state, and the House of Representatives, with number of representatives based on population of the state. In the APTA, all the Academies/Sections (think specialty areas of practice: acute care, pediatrics, geriatrics, orthopedics, etc) have two votes, and the Chapters (each state and Washington DC) have representatives based on the number of APTA members in that state.  Link to see full apportionment list by state, but here's a tiny snapshot of the top of the list:

Just like in American politics, states with more members have a bigger impact on the direction of the profession. States also have Alternates, which was my role, which are included in all the regular meetings, but don’t vote unless one of the elected delegates isn’t available. According to this document, there were 73,525 members in the APTA as of July 2021. This includes professional Physical Therapists and Physical Therapist Assistants, but not our student members, which push our total membership closer to 100,000. I was curious, so I looked for comparisons from other large medical associations and found that the American Medical Association has about 250,000 members, the American Dental Association has about 160,000 members, and AOTA, the American Occupational Therapy Association, lists about 65,000 members. 

Delegates meet with their Delegations throughout the year, led by their Chiefs. Regionally, Chiefs gather at regular intervals to discuss what’s happening across the country and what groups are working on at their local levels. The whole group meets annually at the House of Delegates, led by a Speaker of the House. The purposes of the House of Delegates meetings are 1) to elect new officers to the Board for the APTA, 2) to debate and vote on motions to move the profession forward, 3) for the elected leaders of the Association to have opportunities to meet, network, recognize individuals who have done impactful work, and 4) learn about different topics related to leadership.  This year, House of Delegates was embedded into an entire Leadership Conference, including many students as well as the Delegates. If you want to find out who your Delegates are, you can search the rosters here. 

I've said Delegates too many times already...  So how about some of the work they're doing? How does a motion come to be?  In January, the elected representatives from Washington met for our regularly scheduled monthly meeting to brainstorm ideas for work that we would like to see done by the Association.  We came up with several possible ideas and broke off into smaller groups to do some early research on the topics, come up with basic rationale for why we felt the concepts were important, and then expand the concepts into more detail at subsequent meetings.  The group voted on each idea, deciding which ones we wanted to dedicate our time and effort to, and which ones did not seem to be optimal for continued work.  This year, Washington presented three motion concepts to the House of Delegates and members of our group spent about six months working on them. 

An important piece of motion development is collaboration with other Academies or Chapters.  Consider that priorities around the country differ, payment models are not the same state by state, challenges to patient care practices differ depending on the Academies and variation between settings.  So early on, we identified potential groups that might be helpful as co-makers to the motions, helping to develop statements in support, who would likely want to pursue the same outcomes.  For our three motions, we collaborated with three different Chapters and one Academy as co-makers.  I primarily worked on RC 16-22, APTA as an LGBTQIA+ inclusive organization in collaboration with the Academy of Leadership and Innovation and PT Proud, which ultimately passed by over 90% vote.  

There's a whole process that the Chief facilitates to take the motions and escalate them up the chain of the APTA to be reviewed by a Reference Committee (which I think makes sure we're not going to violate any of our own previous rules and regulations or any laws, and gives input on the language being used) as well as sharing the motions with the rest of the country's delegates for feedback and discussion.  Washington's Chief, Murray Maitland, had to do a lot of work to get our three motions reviewed and heard on the floor. Over time, updated versions are developed and the content and language can change until the minute it is debated on the floor of the House and voted on.  

This year the House had 22 motions up for debate, but did not end up completing the whole list, running out of time.  The whole operation follows Roberts Rules and Parliamentary Procedure and stays on time with an agenda - which can be amended - but which this year's delegation voted not to amend to increase the time.  It was really unfortunate because there are some really important issues that were waiting to be voted upon.  I pretty much live-tweeted the House of Delegates so you can find a barrage of my tweets from August 14th and 15th from me sharing how things were progressing as we worked through debate and voting.  

I could probably write a small book about my experience at the House of Delegates, but since I will

 Bringing RC 16-22 to the floor for vote

now have two more to attend in the future, I think I'll save those for another day.  It was incredibly exciting working on an important motion that will hopefully improve Diversity, Equity, and Inclusion in our profession.  It was amazing meeting the physical therapists who have worked so hard to shape our profession for many years - and who the leaders of tomorrow might be.  I hope this is helpful to anyone who is considering APTA membership. Know that your state IS impacted by your membership and that a small group of new members could influence how many delegates your local group has to vote on issues in the future.  I also hope that it helps more people to understand what APTA Delegates do - so if you have an issue, APTA member or not, find your local Delegates and share your concerns so they can try to help.  Feel free to reach out to me if you're looking for ways to get involved!

Blood Thinners, Anyone?

Pulmonary Emboli

I couldn't let today go by without acknowledging an important one year anniversary.  Woohoo! Let's celebrate!  On this day, one year ago, I learned that I was the proud owner of "a shower of pulmonary emboli." They're gone now (at least, I think they are... once you do treatment, you don't actually test again unless you have symptoms!)  Thanks to six months of miracle drug Eliquis - a blood thinner that meant I bruised if I came even close to bumping into furniture - my lungs are back to functioning.  So now that the scare of having blood clots in my lungs is gone - and since this 2022 paper indicates that having COVID-19 can increase your risk of having a blood clot (deep vein thrombosis or pulmonary embolism), I figured I would share my story in case anyone notices anything related.  Here it is.

Before my parents got sick from COVID, my mom was pretty sick for all of 2020.  She was having regular blood transfusions and her physicians couldn't figure out why her iron levels kept dropping so low.  There were many months of hospital visits during which she had to go alone because of COVID.  She really hated that.  Anyways, feeling very helpless for my mom's medical condition, I started to donate blood.  As a non red meat eater, I had tried donating in the past, but had always been rejected from my own anemia. I knew I couldn't possibly provide as much as she needed - plus we weren't even the same blood type and lived 3,000 miles apart.  I know she appreciated it because we texted back and forth at our appointments and she shared what she was going through. Maybe someone else's mom got my blood in Seattle and their daughter was donating in Florida. 

Click to Donate Near You!

Anyways, I went to donate blood in early April 2021. As usual, first they checked my pulse and heart rate, and my pulse quality was OK, but my heart rate was 120. (Normal resting heart rate should be between 60-80 bpm so all these readings are high.  Maximum heart rate can be estimated by 220-age, so the maximum my heart rate should technically get is 184).They decided to check my iron and if that was good, they would give me 10 minutes to get rid of the "white coat syndrome" - which I guess sometimes even health care providers have, where your heart rate or blood pressure goes up because you're anxious at the doctor's office - but which I've never experienced before.  My iron was way too low to donate, so the nice lady at the donation center told me I should make an appointment to see my PCP.  I thought - no way! This hadn't happened since I started donating blood the year before, but my iron was often too low when I tried to donate in high school and college. I figured I didn't eat enough dark chocolate or spinach that week.  After all, the timing of this blood donation was in my third week back to work after being on FMLA and my grief felt like heavy fatigue for weeks.  I just went home, rode my bike for 20 minutes, and made a turkey burger for dinner. 

A few days later, I was walking up a flight of stairs with a coworker when he asked me if I was ok.  We had walked into work together many times before, always taking the stairs, so for him to notice my breathing was surprising to me.  I thought maybe I was breathing differently with the mask I was wearing that day, but I didn't feel bad otherwise. Thinking about the failed blood donation, I grabbed the clinic pulse oximeter and my heart rate was again in the 120's.  I felt fine, so I continued the day, treating my patients, not really noticing anything.  The next morning I showered, got dressed, and was tying my shoes and with the bending over motion, felt instantly short of breath.  I checked my heart rate by hand, but didn't believe my own count so of course I dug out my own pulse oximeter and my heart rate was in the 130's. Having a quick moment of panic, I recalled my dad having a heart attack when I was eight - he was 48 - and thought - maybe I should get this situation checked out.  So I hopped onto my PCP's patient portal and made an appointment for later that afternoon and went to work, figuring it was too late to cancel my morning patients and if I wasn't moving, I felt ok. 

At work I took the stairs again, but this time, when I got to the top, I had to sit down, unmask, and catch my breath. I was sweating and had a little bit of pain between my shoulder blades. Something definitely wasn't right. I told my boss right away that I needed to cancel my afternoon patients to see my doctor and explained what was happening.  It only took demonstrating one repetition of a 15 pound goblet squat to a patient for me to know it was getting worse.  I finished my patients, sat down to write my notes, rechecked my heart rate at my desk - now 154 - and felt the veins in my neck pulsing.

As previously mentioned in other blog posts, I have a BFF who is an emergency medicine physician. Everyone should have doctor pals they can call in an emergency... but this still didn't feel like an emergency.  Still, I called her as I was driving to my doctor's office and she advised me to cancel my appointment and tell them I'm going straight to the Emergency Department.  Then, instead of going directly to the hospital, I should go home, get my cell phone charger, a hoodie, maybe some pajamas,  my toothbrush, and a book, and then go to the hospital.  (If you EVER need to go to the emergency room and have enough time to make these sort of decisions, bring your cell phone charger!).  She also wouldn't hang up the phone until I got there.

The walk from the parking lot into the emergency room left me drenched in sweat.  The lady at the

waiting on CT Scan

check in desk asked me the COVID screening questions, none of which applied, but since I was sweating, she didn't believe that I might not have just had a fever breaking.  So she asked a nurse to come take my vitals right away, heart rate still in the 150's, but since my temperature was normal, I could sit and wait in the lobby.  It was a long wait.  Honestly, without moving, I could still feel my heart racing and some aching between my shoulder blades, but otherwise I didn't feel that bad.  When they took me in for my exam, the physician asked me what I thought was happening and I told her I thought I had a pulmonary embolus but that it was weird because I didn't really have any chest pain.  S

The next moment could have gone so differently, but instead of just shrugging off that I'm "just" a physical therapist, she asked me to defend my own diagnosis. I explained that my schooling educated me enough to know that if I saw a patient that described these symptoms, I'd be worried, but that one course in the cardiopulmonary system in grad school and another in college made me far from an expert.  I explained that I had flown across the country five times over a three week span just a few weeks prior without any hydration and immediately following my vaccinations and under intense stress.  (At no time did anyone, including myself, think that my vaccination caused these blood clots.  However - I did get sick from the vaccines, likely because I was not willing to unmask to drink any water or eat anything on my flights immediately following them. Plus grief.)  She asked if I took birth control, because "the chance of clots is 2 to 6 times greater among women taking the pill compared to those who don't use birth control" and when I said yes, for nearly 20 years, she felt confident that blood clots were the appropriate place to start the diagnostic hunt.  Let me tell you - some people get REALLY awkward talking about birth control.  I am not one of those people.  Three different medical providers AND a social worker came to discuss birth control with me.  I'm not sure why it was like that... but I do think we probably should be educating teenagers more about this risk if they're considering mixed hormone oral contraceptives, just so they're educated.  Maybe my doctor told me about this risk when I was 18... for sure I do not remember. 

The doctor applauded me as a healthcare worker listening to their body because I guess that's something we're really bad at doing.  I did wait several days, I guess, but it for sure could have ended much worse.  She felt that my assessment was reasonable, so after a Covid test, which was negative, we proceeded through a chest X-Ray and D-Dimer blood test.  When the blood test came back positive, there was a chest CT Scan and then a diagnosis of "a shower of blood clots" in my lungs. I was on blood thinner medication six hours after leaving my desk and held on observation in the hospital for the night.

At which time I finally called my sister in Connecticut and my brother in Washington, D.C., and told them where I was. Let me tell you - being alone in the hospital because of COVID restrictions limiting guests is horrible.  I didn't want to tell too many people where I was or make a big deal out of it because we had identified the problem and medication had been started.  The doctor told me I would feel better fairly soon, and I was back at work five days later with a 20 pound lifting restriction.  I spent my down time searching for research papers about exercising with pulmonary emboli because my doctor told me that I was OK to be active as long as my heart rate stayed under 150... but it was still 150 at rest, so it started with walking for 10-20 minutes or biking without resistance.  I used the elevator at work for a few weeks.  I didn't lift weights. And slowly, the pain between my shoulder blades started to improve and I was able to go up the stairs without stopping.

This week, I returned to the scene of the crime and I was able to donate blood again!  I have to take iron supplements and they make my tummy hurt, but I've found ways to manage that.  My resting heart rate was 84 when I went - still a little bit high, but considerably improved.  My cardiovascular endurance is still limited, but I can ride the bike for 45 minutes.  More difficult for me is the time it takes to recover.  I can't do cardio on back to back days and my legs sometimes feel like bricks after I ride.  I think it's more deconditioning... but it's slowly improving.  And my personal favorite - I can lift over 150 pounds when I'm deadlifting, working my way up to 200.  I feel like that's going to happen before the end of the WNBA season that's about to start.  Last season started about 2 weeks after I was in the hospital and I remember that I couldn't yell/cheer because forceful exhalation made me light headed to the point I thought I might pass out. I can't wait to test that out again!  Other than wearing compression socks and taking aspirin to fly on airplanes, I feel like I've recovered pretty well.  I don't recommend it for others, though.  It isn't fun. 

Please donate blood if you can.  It's basically a free health screening for you and a life-saving gift for another person.  It takes less than a half hour to do and you can repeat every 2 months. 

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. 

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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:

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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.

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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. 

"Pain is ALWAYS both physical AND emotional 100% of the time."

As a Sports Physical Therapist at Seattle Children's Hospital and a member of their Pain Medicine Team, I work with many kids experiencing chronic pain. Most often, that includes seeing teenagers who can't tolerate going to school, hanging out with their friends, or participating in their favorite extracurricular activities. Sometimes it's even worse: kids who haven't been able to put a shoe or sock on (or walk) for many months because of chronic regional pain syndrome, which means a very long road back to their previous level of function.  Their pain could have started long ago with an injury or illness, and will hopefully improve with graded exposure to movement while learning about pain.  These patients can experience massive improvement in their lives if things go well.  I'm not crazy enough to think I can help everyone, but I've grown to embrace this work, including when I can't help my patients break their pain patterns.  To help kids with chronic pain with any success has required a commitment to collaboration with other healthcare providers and dedication to learning about pain neuroscience and pain management. To do that, I read. A lot. 

I also read a lot when I'm preparing to give a presentation.  This week, I was invited to talk about Pain Neuroscience and the Pain Medicine Clinic to the Seattle Children's Regional Rehabilitation Team. I like presenting because it requires me to focus learning on a specific subject and makes me seek out new resources. Educating clinicians is very different than patient care and it helps me consider my own beliefs, biases, and treatment approach.  I was fortunate to be partnered with Hematology/Oncology Physical Therapist Dr. Jacob Ross, who spoke about the intensive Pain Rehabilitation Program (PReP) where I sometimes refer patients when they need more care than 1 or 2 hours per week in my clinic will achieve.  If you're seeing Jacob at PReP, you're undergoing rehab or mental health or some school work Monday through Friday from 8AM-4PM for anywhere between two and four weeks! Based on this website, there are 83 pediatric pain clinics around the world, mostly (65%) in the United States, existing in 25 states plus Washington, D.C.  That means half of the states and the majority of the world doesn't have this available at all - and if you consider that the states who do offer these type of services only have it in a small number of places, tons of kids with chronic pain have no access to this care! In Seattle, I've worked with families from Alaska, Montana, Idaho, and Washington - and there are probably patients from many more places that my team members have worked with. 

If you're interested in learning about pain, I recommend you start with the work of Lorimer Moseley.  I've previously written about his books: Explain Pain, Explain Pain Supercharged and the Graded Motor Imagery Handbook, and I wrote about hearing him lecture and meeting him at the University of Washington, here. The NOI Group, who published those books, announced a new one coming out in December, "Pain and Perception: A Closer Look at Why We Hurt" which will be my next pain-related read.  From a different perspective, I also wrote about The Gift of Pain, which describes what happens when people are without the ability to experience pain. You don't pull your hand away from a hot pan or stop walking on a broken leg if you can't experience pain - a very dangerous scenario.  If you came upon this post looking to learn about pain management, any of those resources would be great places to start, but they're more about educating clinicians and, though they may be helpful for patients, I've now read a workbook more specifically intended for patients and think it's a great addition to this list.  

$19.95 on Amazon!

In preparation for our presentation, Jacob asked if I had heard of Dr. Rachel Zoffness. "Why yes, Jacob, I have. I follow her on all the social media and listen to her podcast episodes (OMG listen here or here or here or definitely my favorite: here), and I just finished reading one of her books."  The Chronic Pain &Illness Workbook for Teens was published in 2019 and was the first new resource I read for my presentation. Dr. Zoffness is a Pain Psychologist who teaches for multiple higher education institutions, she is the Co-President of the American Association for Pain Psychology, and she is on the Board of Directors for the Society of Pediatric Pain. Oh, and she treats patients experiencing chronic pain and has written two books. (She also wrote The Pain Management Workbook which I'm currently reading.) She's also released an $80 Workshop "Foundations of Pain Psychology" and more from that series are coming soon! Hopefully I'm not starting to look like a creeper because I've been fan-girling and re-sharing all her posts, podcast episodes, and books, so writing a blog about her work is probably the icing on the cake. When you find someone who can directly impact your patient care and knowledge, with easily digestible tools and clear, consistent messaging, I think you have to tell everyone.   

If this is your first time reading one of my blogs, you might not know that I write to organize and synthesize information I'm learning to refer back to or share with others.  Today's post starts with a look at a few of my favorite points from Dr. Z's Teen Workbook paired with information from two of the research papers I read for my presentation and it wraps up with a look at another pain management workbook from Dr. Greg Lehman. 

If you're a person living with chronic pain OR a clinician who works with patients experiencing chronic pain, in-person multidisciplinary care is the best treatment option, but that isn't available or affordable or feasible for so many people. The Teen Workbook could be a solution for patients who need something they can do independently.  It doesn't replace physical therapy or mental health counseling (or the many other treatments that may be appropriate and necessary), but it can certainly help educate patents and initiate behavior change that may be life changing.  

Jull 2017

1) Let's start with my favorite quote from Dr. Zoffness:"Pain is ALWAYS both physical AND emotional, 100% of the time."  This is the biopsychosocial (BPS) model at its heart and connected well to this image from Jull 2017 that I spent a lot of time discussing in my presentation. The Jull paper is a commentary on the BPS model and shows the idea that 3 different patients may have different amounts of biological - psychological - and sociological needs.  But also, the same patient at time 1, time 2, and time 3 has different amounts of these domain needs, too.  Today, for example, I might have a mild headache and I'm hungry but my mental health is good and I got to spend some time with friends so my social bucket has been filled, but my biological bucket may need more attention (maybe a sandwich for my blood sugar).  Tomorrow, I might have eaten enough for breakfast but be stressed about my pain presentation at work and spending a longer day at the office missing out on game night with friends - so my biological needs have been met, but not the social pieces that keep me going. You can't just look at your patient and think they only need biological care or mental health care at your evaluation and then assume it stays the same for all of their treatment.  I

The Workbook is clear about the role of the mind-body connection with regard to pain and explains what parts of the brain are involved.  It provides concrete examples, intentional questions for patients to consider, and a roadmap of strategies to try to better understand your own pain triggers from each of the three circles and identify solutions to try to reduce your pain volume.  Some of the pain books I mentioned above were really complex but this one is, without question, the easiest to understand and most user-friendly option for the general population, particularly when considering teenagers.  Too often the "Bio" portion is treated alone, with Physicians and PTs attributing pain to tissue damage or disease, but that (biomedical) approach ignores two major domains that impact the patient's presentation (Psych and Social circles). The unity of physical and emotional care is essential to patient success and Dr. Zoffness is screaming this message from the rooftops for everyone to hear.  I'm happy to amplify her message as often as possible to whoever will listen.  I actually ask my patients  "How's your mental health today?  Anything stressful going on?  When are your exams?  Have you done anything fun with your friends lately?"  If it's OK to ask them how their ankle is after they've sprained it, it should certainly be OK to also ask these questions.  Clinicians: please consider adding this to your day to day interactions with family, friends, and patients - and I don't just mean handing them the depression questionnaire and glancing at it.  Look them in their eyes and ask them how they're doing.  And mean it!

Tale of Two Nails

2) Metaphors, Analogies, and Stories help teach pain. It's no surprise that Lorimer Moseley is a mentor to Rachel Zoffness (and Greg Lehman) because they all use many of these to get their points across. I presented a few in my talk, also, but have a few favorites I use with patients.  One example that I liked from the Teen Handbook is about practice.  Think about an activity you wanted to learn. She uses playing piano, but I'm using basketball. At first, your hands struggle to dribble without staring at the ball and using your palm instead of your fingertips and the ball might bounce off your foot or miss the rim when you take a shot.  As a novice the task is more difficult and requires more effort and concentration.  So you practice.  And over time, you get better and better, until at some point, you've stopped looking at the ball and can run while handling it and can make shots from farther away and your form looks more consistent as it becomes automatic.  Your brain has developed new patterns that have been repeated enough times that the task is now easy.  With chronic pain, you're unintentionally practicing pain and your brain develops patterns that make it easier or more automatic to have pain.  The beauty of this is that with the appropriate treatment, the pain and learning can change.  Another example Dr. Z has written about, is "The Tale of Two Nails" which tells two really great stories that can inform our understanding of pain - but you should read those directly from her - so check out the article or buy her other book, because it's in there!

When Dr. Z is talking about practicing pain, she's explaining central sensitization, a phenomenon that I previously was struggling SO MUCH to understand. Central sensitization is a common characteristic of chronic pain, where you have an increased response to sensory stimuli resulting in hyperalgesia (increased sensitivity/bigger pain response to the same sensory input) AND allodynia (painful response to something that is normally not perceived as painful like hurting when you're touched by a feather on your skin.) Your nervous system changes when you experience pain for a long time. 

For my presentation, this 2011 Clifford Woolf paper depicts normal sensation compared to central sensitization.

Normal Sensation: On the left side there is an input - either something noxious (potentially dangerous - top) or a light touch (feather, bottom). Notice the black arrows for the top path (pain) and the bottom path (touch) don't converge and the brown blob (brain) is the same color as the rest of the  nerves.

Central Sensitization: Here, the same sensory stimulus occurs at the far left, but now the black arrows merge to the same destination (brain) and the color has changed because the system has adapted resulting in hyperalgesia and allodynia responses. 

3) It's a workbook: there are pages for you to do work.  This isn't just a book of education about pain. This is a guide with explanation of a key pain-related concept followed by actionable items to help improve your experience.  Sometimes I feel like patients who have had pain for a really long time are desperate for a physical therapist to DO whatever we can TO THEM hoping to dull the pain for just a few minutes.  What we really need is to serve as a guide, showing patients what THEY can DO on their own to turn down the pain.  They have to take control of their lives and do the work for any success to occur.  Physical therapists in chronic pain management should be cheerleaders, rooting on our patients as they make 1% progress day after day. People don't need to be 100% to live their lives fully, and often a really small amount of progress gets the ball rolling for a lot more progress to occur. I don't think patients realize how much control they have over their pain until someone empowers them to trust the process and themselves to get moving.  

Link

So, let's say you like the idea of a workbook and want to have multiple options to choose from, or you're an adult and want something a little deeper into the science. As I mentioned, I haven't yet finished Dr. Zoffness's other book, but I expect it might target that audience a bit more. There's another workbook I really like and was using prior to reading Dr. Zoffness's book. Dr. Greg Lehman's "Recovery Strategies" Pain Guidebook is available for patients or clinicians to access online.  I've previously written about attending his "Reconciling Biomechanics with Pain Science" course here and have appreciated learning from him both at the course and from his online presentations and social media. 

The workbooks are similar in their intent and both include key focus on the BPS model, describe how pain works, and provide action items for you to follow.  And both have many metaphors, analogies, and stories.  In particular I liked his metaphor for what happens to the brain with chronic pain: Consider that our brain is like a map of our body, and that a good map would be really clear, showing all the roads and rivers, but that with pain, things get smudged, almost as if you've spilled coffee on the map and the details get a little fuzzy.  The details of our body can get a little fuzzy with chronic pain, but with exercise and movement, we can clean up the coffee mess and the map gets clearer.  Overall, though, they're really quite different.  Dr. Lehman's book is written as a series of infographics, almost a choose your own adventure graphic novel, where you can take a single page out of it to educate your patient.  It includes pages of mythbusters, examining common misconceptions about various topics like "bones out of place," or how tissue damage found on imaging like an MRI doesn't always correlate with pain.  I think Greg's goes into more detail on how pain processes occur, looking deeper into the science of the nociceptive system, the spinal cord, and the brain, but he also acknowledges that it's meant to be used for patient and provider together because of its level of complexity. 

Also, I think that because Greg is a biomechanist, chiropractor, and physiotherapist, his handbook comes through from a more musculoskeletal lens. Though he fully emphasizes the BPS model, he's more from a bio background and gives adequate attention to the other bubbles.  Rachel is a pain psychologist who comes from a more psycho-social background, and thoguh she gives adequate attention to the bio, it's super interesting to look at their two workbooks and consider how they're trying to reach the same outcome for patients from different angles.  I think that patients would absolutely benefit from both. 

That's all for now.  December's blog post is about grief.  It's another long one and recommends several books on that topic, too. So if you're looking for holiday gifts that are books on pain, start with Dr. Zoffness's books - or if grief books might help one of your loved ones, there are several being reviewed next month.  Stay tuned!

TL;DR:

1) "Pain is ALWAYS both physical AND emotional, 100% of the time." 

2) Your nervous system changes when you experience pain for a long time.  This is called central sensitization which is characterized by hyperalgesia and allodynia. 

3) Teaching people about why we have pain and how the pain process works has been shown to help improve pain.  Multiple resources are listed to learn more about pain, often using metaphors, analogies, and stories to demonstrate complex concepts and make them more easily understandable.

4) The biopsychosocial model indicates necessity in attention to the biological, psychological, and social domains in treatment of chronic pain.