Applied Neuroscience & the Paining Person

This is the second post in a three-part series about the San Diego Pain Summit.  You can find part one here and part three here (coming soon). Part one was a look back at all the Pain Summits prior to 2023.  Part three will share highlights from the February 2023 Summit.  

This post summarizes what I learned from the two day pre-conference workshop with Dr. Morten Hoegh entitled "Applied Neuroscience & the Paining Person."  It combines Dr. Hoegh's teachings with the tangled web my brain weaves when I try to make connections between what I'm learning and things I've thought of before.  Dr. Hoegh's bio from the Pain Summit Website along with all the other 2023 Speakers' Bios highlights that he is a physiotherapist who specializes in musculoskeletal and sports physiotherapy, has a Master's of Science in Pain: Science & Society from King's College in London, and a PhD in Medicine/Pain from Aalborg University in Denmark. (Fun fact: in Denmark, they speak Danish.  Don't be the dummy - like I was - who incorrectly thought they speak Dutch... Dutch is spoken in the Netherlands). Dr. Hoegh is an Associate Professor at Aalborg University and lectures around the world.  He also provides patient care, which I think elevates his ability to teach to practitioners, because he understands how to apply it to the people we're working with.  If you're interested in seeing his publications and learning more about his pain research, his Aalborg University Bio includes links to those. He also offers a Course on PhysioNetwork called "Pain: A Guide for Clinicians."

Morten Hoegh: humanist, skeptic, pragmatist

Dr. Hoegh started off the course by introducing and describing himself as "humanist, skeptic, pragmatic."  Here come some definitions.  Humanism: "an outlook or system of thought attaching prime importance to human rather than divine or supernatural matters. Humanist beliefs stress the potential value and goodness of humans, emphasize common human needs, and seek solely rational ways of solving human problems."  As a somewhat religious person who is constantly overwhelmed by my emotional approach at solving patient issues and occasional beliefs that a higher being has directed life, this descriptor was novel to me.  I've previously written about the collide between science and religion, evolution and creation, here. Ironically, my own therapist often tells me I'm approaching my mental health too rationally rather than emotionally, so perhaps there are parts of this system I apply to myself, but not sufficiently to my patients. 

Skeptic: "a person inclined to question or doubt accepted opinions." How self aware to know you're like this. I want to question my own beliefs and critically analyze things I'm learning rather than believe on first hearing. Perhaps I am now a wannabe skeptic. I think skepticism makes for improved clinical reasoning and evidence-based practice, supporting the ability to critique and seek alternative solutions. It's interesting to see how Dr. Hoegh exhibits his skepticism throughout his talk... with statements that really make you question your own beliefs.  I wonder who else would proudly call themself a skeptic.

Pragmatic: "dealing with things sensibly and realistically in a way that is based on practical rather than theoretical considerations." Dr. Hoegh spent time discussing how most (all?) theories are wrong AND how they can also be useful, but if you're applying a theory, you need to recognize the limitations of where the theory can be appropriately applied. If you do something and it works, you're likely to keep doing it, even if it doesn't always work. In an effort to learn more about theories, I found this article that I found interesting discussing the difference between Scientific Theories and the use of the word theory in everyday practice. It states, "A scientific theory is accepted as a scientific truth, supported by evidence collected by many scientists. Lots of data has been collected to support theories, and no data has been identified to prove theories incorrect. That does not necessarily mean that evidence does not exist against a theory does not exist, it simply means that evidence has yet to be identified." I actually think Dr. Hoegh is a philosopher, but perhaps that's too theoretical for his liking.  

It would be wrong of me to share a play by play of Dr. Hoegh's course because I will not do it justice and he gives lectures around the world worth hearing directly from him.  Instead, I'll share the big picture take-away pieces about the biopsychosocial model, the classifications of pain, and peripheral and central sensitization.  I won't touch upon descending modulation because - even though it was part of the course - I still don't understand it well enough to describe to another person.  More for me to study at a later time!

Medical Models:

Looking through the history of medicine, illness has always been connected to a specific cause. This makes it much more difficult in current times when clinicians can't identify an underlying cause of a patient's illness or pain. The evolution of Medical Models helps us to understand where we've been - where we are now - and what's still missing.  

As far back as medicine can be studied, an evil spirit or demon was thought to cause pain or illness in some religions and cultures. There was a clear separation between the body and the soul (dualism) and healing was conducted through Shaman who drove away the evil spirits to restore the body. I read this article "Judeo-Christian Concepts Related to Psychiatry," for more details, opening my eyes to the potential influences of religion on medicine and health. So, in the Beginning, there was a cause - evil spirits or sin - underlying the effect of pain or illness. With development of improved science and medicine, beliefs that other things - like bacteria or cells caused illness or that tissue damage caused pain - continued to evolve.  This cause/effect relationship is a feature of the Biomedical Model and is pervasive for those who believe that physical health is separate from mental health. (I do not believe this and have previously written about that here.) 

The Biomedical Model is a theory in which biological issues (think back to biology classes: cells, anatomy and physiology) are the underlying cause of disease. But as we know now, pain is far too complex for this reductionist thinking: "the practice of analyzing and describing a complex phenomenon in terms of phenomena that are held to represent a simpler or more fundamental level, especially when this is said to provide a sufficient explanation." Is it possible that sometimes a tissue injury results in pain for a human?  I believe it is - however there are multiple factors that need to be considered in addition to the tissue injury that impact the individual's pain experience.  The same tissue injury in multiple people will not be experienced in the same way.  Pain - and illness - require broader thinking to understand, evaluate, and treat. In 1977, George Engel wrote his landmark paper challenging the Biomedical Model and naming the Biopsychosocial Model, a more integrated approach adding psychological and sociological considerations to the biological contributions. This updated model does not remove the importance of biological contributions to illness.  Rather it expands the potential contributors to a broader picture that more wholly encompasses the patient's environment, beliefs, emotions, behaviors, body, and mind.

The biopsychosocial model is not meant to outline the cause of pain, though. We need to step away from the cause/effect relationship and think more about a complex interwebbing of multiple characteristics of our patients where it's not helpful to our patients to identify specific causes.  We need to get more comfortable being uncomfortable and sitting with uncertainty.  More and more frequently, particularly in circumstances of chronic pain, the truth is that medical providers do not know what is causing the pain.  Why?  BECAUSE THERE IS NOT ONE CAUSE!  I think the concept that had the most impact on me from Dr. Hoegh's talk was "You have pain, period" compared to "You have pain, because..."  I've now shared this conversation with two coworkers in my clinic - here's how that played out.  My coworker, also a physical therapist, was evaluating a patient with a complex chronic pain diagnosis while I had documentation time so instead of writing notes, I sat in on his session.  He looked at her mobility and strength, the patient's parent commented on their poor posture, an exercise program was provided that looked like it was meant to directly impact the patient's posture. Afterwards, I said to my coworker - "Do you think that patient has pain because of their posture?" and he said no! But the parent's expectation was that we needed to "correct" posture to "fix" the pain. No... the exercise program he provided looked very similar to what I would have done. It's really hard to dispute patient's and family's beliefs at the first meeting, but the language I would have used would have been to challenge the beliefs about posture as the because, explain that pain is multifactorial in nature, and get the patient moving. (Don't get me started on how much it hurts my soul when parents look at their children as if they're broken because they're experiencing pain.  Your kid is not broken!  Unless they have a fracture, and then, still, a piece is broken, but they're still a whole child!). 

I think the development of the biopsychosocial model is a valiant attempt to reverse the reductionism of the biomedical model.  Many medical providers still live in the previous biomedical model world where something happens to anatomy and they believe this causes pain.  However, the biopsychosocial model encourages us to look at the human as a whole, taking into consider their biology along with their psychological and sociological environments.  There are still problems with this new approach, however, if medical providers blame the biopsychosocial findings as the cause of a patient's pain. That's not how the model is intended to be used, and all too often the model is broken into it's components with each considered separately.  The patient in front of you needs to be treated with consideration from all these perspectives holistically in an effort to individualize the best possible patient care. The biopsychosocial model has been broken down into separate parts for providers trying to determine if a person's pain comes from their bio, psycho, or social, when really the biopsychosocial model is not a model of pain - but rather a model of looking at illness and health for the human as a whole person who has a unique environment and history.  The biomedical model is already a big mess for medicine, can we try to avoid the same disaster with the biopsychosocial model? That was a lot of philosophy for a Neuroscience Talk, wasn't it?!

International Association for the Study of Pain (IASP) Pain Classifications

Dr. Hoegh is really quite genius in teaching pain neuroscience.  He's currently in the process of releasing a series called "Pain Science in Practice" through the Journal of Sports Physical Therapy JOSPT, all parts so far are less than 3 pages of digestible pieces about pain neuroscience. They're great.  The course discussed the first five of these papers that have been released and more are coming soon.  I highly recommend them for the new PT and the Painiacs like me to better help understand pain mechanisms. 

Dr. Hoegh's Pain Classifications

Dr. O'Connor's Pain Classification Continuum

In part one of this blog series, I mentioned the IASP Pain Classifications as presented by Dr. Annie O'Connor. Dr. Hoegh used this image (above) to demonstrate the three classifications. Dr. O'Connor used several others, including this one (right). The three classifications are nociceptive pain, neuropathic pain, and nociplastic pain. The goal with patient care evaluations is to determine which classification the patient fits under and treat appropriately. Ready for more definitions?  

First we have nociceptive pain.  This type of pain is related to the body receiving stimuli which achieve a threshold that is experienced as pain. In Dr. O'Connor's image, nociceptive pain is on the top left of the continuum and is associated with ischemic (low oxygen) or inflammatory conditions.  In nociceptive pain, there is no damage to nerves.  Instead, receptors in the skin or inside the body are detecting signals from temperature, chemical substances, or mechanical pressure, and when that stimulus is removed, the symptoms should eventually reverse. This type of pain is typically shorter in duration, and many acute pain conditions would fit into this classification including broken bones, muscle/tendon/ligament injuries, a bladder infection, appendicitis, a heart attack, the list goes on.  

Tooth Fairy © Irina Akolzina

Next is neuropathic pain which occurs when the nerves are directly impacted. This can be tested in rats by injuring nerves in various ways and it can be measured. This commonly occurs with back and neck pain and also with peripheral neuropathies where the nerves are either being squished or they've been stretched or torn. We commonly see allodynia: when typically non-painful stimuli hurt and hyperalgesia: increased sensitivity to stimuli with these patients as the nerves are protecting the body from further nerve injury.  

The third classification, nociplastic pain, is where things get more complex. This classification isn't really a "thing." It's more like... "pain that's not the others and doesn't have a known underlying cause but we needed to have a name for it so that we could talk about it." Dr. Hoegh referred to this classification as the tooth fairy. It has a name in order for researchers and clinicians to label it and write about it and try to find underlying mechanisms and treatments and medications, but the underlying cause is unknown.  As you can see from Dr. Hoegh's Pain Classifications image, a question mark stimulus elicits a pain response. From Dr. O'Connor's image, nociplastic pain is likely to be more chronic in nature, there are behavioral (affective) considerations as we mentioned in part 1, the autonomic nervous system which regulates heart rate, respiration, and excitation may be involved.

Nociplastic pain is the category that most frequently matches the patients I see at the Seattle Children's Hospital Pain Clinic and who often require a multidisciplinary approach to their recovery - because the underlying cause is unknown. This is a great place to re-iterate, "you have pain, period, rather than you have pain, because..." It really doesn't help to provide patients with a "because" if it's wrong, if you can't prove it, if there's plenty of research saying that the "because" you're using isn't a cause of pain (like posture), or if there isn't a known treatment for that cause. There are many other images online describing the three classifications.  One other that I found and wanted to include, particularly because it resonated as some patients really present like they're in hell, I've included here. The patients know they're experiencing more than "just" pain - their lives are impacted and they're the ones who know best what's happening inside their bodies.  It goes so much deeper and we need to treat accordingly. 

Peripheral and Central Sensitization 

This is the meat and potatoes.  This is the part that I see in my patients, scratch my head, and wonder why it's happening for so long instead of going away. Both Peripheral and Central Sensitization are cases of the nervous system being sensitive. Things that wouldn't normally hurt, now might - or things that would hurt before, hurt more than they previously did. 

The Central Nervous System includes the brain and spinal cord - so the underlying mechanisms of Central Sensitization occur there. The Peripheral Nervous System is the rest of the nervous system, all the nerves that come out from the spinal cord and provide sensation and movement to the rest of the body.  

JOSPT Pain Science in Practice #3 Peripheral Sensitization

Peripheral Sensitization is sensitive to heat where central sensitization is not - so if a person was complaining of pain and you applied heat, worsening symptoms could indicate peripheral sensitization. At the time of an injury, sensitization is normal! You broke your leg - a sensitive leg reminds you not to put weight on it! The picture shows peripheral sensitization where an injury (far left) results in inflammation (all the little balls) and that inflammation is a bunch of chemicals that attach to different receptors on the nerve (blue part on the right).  If the inflammation continues to occur, the receptors on the nerve get more sensitive to them. So in a nociceptive pain situation, the injury occurs, inflammation happens, and then the tissue heals and inflammation stops.  In a nociplastic situation, the tissue heals, but for some reason, the sensitive receptors remain sensitive.  This may be related to the mast cells (purple blob) or the immune cells (brown blob) which also give out inflammatory chemicals. 

JOSPT Pain Science in Practice #5 - Central Sensitization

In Central Sensitization, the scenario is similar, but the location is different and the body impact is a bit different.  Now the changes occur in the spinal cord or brain. So in this schematic, the top left corner is similar to the peripheral sensitization photo described previously: injury to the body occurs and the nerve is set into action. Initially there would be inflammation at the periphery where the injury occurred, but over time and with normal healing processes, that inflammation resolves. Instead, the peripheral nerve conducts signals along it's pathway to the spinal cord nerves (right side, big blueish gray circle) and here inflammation (all the little balls) occurs, acting on receptors in the central nervous system.  When this has happened for a long time, the receptors could become more sensitive to the inflammation or more receptors could be made which makes a change in the system.  When that happens, if a feather touches the skin, which wouldn't normally hurt, the signal is passed along but since the spinal cord is more sensitive with these receptor changes, the body produces a pain experience (hyperalgesia and/or allodynia).  This is part of pain neuroscience.  I mentioned in part one that I don't teach this to patients.  It's so hard for me to understand, and I'm sure that if Dr. Hoegh ever reads this, he could point out all the areas where I've got it a bit wrong.  The big concepts about the body becoming more sensitive, however, sometimes help patients to cope.  Their bodies are actually doing what they're supposed to be doing - protecting from future damage - even though it doesn't feel good.  Both peripheral and central sensitization are features of chronic pain, but again, they're not the cause of it and they do not explain why it's happening.  

Me with Dr. Morten Hoegh

A final thought about therapeutic alliance. As always. I've written about therapeutic alliance in several blog posts, this one probably being my favorite. Dr. Hoegh wrapped up his two-day talk with great reminders about the importance of the patient-clinician relationship. It truly does not matter how much pain neuroscience you know if you can't connect with your patients.  Can you empower your patient, even when they're in pain, to finish a session with an "I did it!" feeling? Can you help create situations where they meet success after success after success and stop a potentially perpetual cycle of failures?  Can you find a topic to talk about so your patient who has depression and is sad has a moment of laughter or joy so that there is positivity breaking up the negativity?  Empowering your patients can be a powerful behavior change tool to get them moving in new ways to change their pain experience.  I once had a patient who was in treatment for CPRS and had spent months in his bed.  He was improving very slowly, but after a family discussion to get some new bedding and a new poster and rearrange the furniture in his room, things got dramatically better.  He had a new environment, a change of habits, and something that brought him excitement that previously was part of his negative state.  Would I say that this change caused his pain to improve?  No.  He had pain, period.  Not pain, because his room was part of the problem.  I'm really excited to move away from pain, because. I hope you'll join me. Thank you, Morten!

San Diego Pain Summit: Through The Years

This is the first post in a three-part series about the San Diego Pain Summit.  You can find part two here and part three here (coming soon).  This initial post is a summary review of the San Diego Pain Summit Talks prior to 2023. My first time attending was in February 2023, so I decided to watch as many of the previous years' videos as possible in the months leading up to the event.  My brain still hurts. Many of the talks led me to read research papers and as I moved through the work, a beautiful web was created as many of these presenters have connections to other presenters. The pain neuroscience and pain management world, it seems, is far-reaching, and also quite small.  Having nearly completed watching all the previous videos, and most of the ones listed below  multiple times, I've compiled the most impactful pieces (in my opinion), organized into three themes: pain neuroscience, pain management, and special topics. You can watch any - or all - the previous San Diego Pain Summit recordings here.

I originally started watching videos from the San Diego Pain Summit in order to learn Pain Neuroscience. Yep... NERD ALERT! Lately there has been debate on social media about the utility of teaching pain neuroscience to patients. The theory was that if patients understood how pain worked, they might be better able to tolerate it and potentially even have reduction in symptoms.  I have read numerous books and written posts about them including Explain Pain and Explain Pain Supercharged in the past, but  I don't actually teach most patients pain neuroscience.  I do, however, find continued benefit as a clinician understanding the neuroscience so that I can better apply it to the interventions I'm choosing.  The level of scientific research presented was impressive, and I’d be lying if I said I understood all this work, but I took away many interesting pieces that inform my patient care.  

Pain Neuroscience

Let's start with animals. In the 2016 Summit, Dr. Robert Sapolsky’s lecture was not recorded, but he permitted his Q&A session to be shared.  Dr. Sapolsky is a Neuroendocrine Researcher who studies stress at Stanford University and who also examined behaviors of baboons and other animals in Africa.  For this he reminds me of my childhood hero, Jane Goodall, though she studied chimpanzees. He is the author of several books, including "Why Zebra’s Don’t Get Ulcers,” which I recently read, and he shares a fun anecdote about how zebras tend to be very social creatures with short memories of their stresses. A zebra could be running away from a lion and once it's free, quickly return to eating grass, seemingly not perseverating on its recent close encounter with a lion. Their stress levels don't persist the same way human stress levels do.  If I can't find my keys in the morning, it's going to keep my stress levels high through lunch time, much longer than the zebra who just avoided imminent death. Dr. Sapolsky describes social grooming - when animals groom one another, removing parasites and eating them off one another - and how this behavior is a stress reliever with associated decrease in heart rate and cortisol (stress hormone) levels.  He explains that each person's level of optimal stress varies from the person next to them. Cortisol, when sustained at elevated levels during a chronic stress state, can lead to illness.  

Dr. Jeffrey Mogil talks mice and rats

Then in 2017, Canadian Neuroscientist Dr. Jeffrey Mogil discussed his research in mice and rats and the concept of translation: conducting studies in animals with the intention of extrapolating information to humans. A big problem in scientific research was exposed because the majority of studies were conducted using either one type of mouse or one type of rat to generalize concepts to all humans.  There have been studies which show that different types of mice reacted differently to the same pain stimulus - so if some mice respond and others do not, the outcome of an experiment would be entirely dependent on which type of mouse was used in the study. This same problem occurs with sex - a single type of mouse, and only males of that type, were studied and then conclusions were applied to middle-aged women, but men and women are not the same! This, he explains, is how pharmaceutical companies could lose millions of dollars.  Testing done with success in a male rat and then later tested on a human woman would show medication that doesn't work and the drug will never make it to market.  At the time of his presentation, microglia: immune cells in the nervous system that impact development of brain networks, were a newer area of study in pain research.  It was determined that microglia might contribute to pain in males, but not in females, who may instead use t-cells: white blood cells of the immune system from stem cells in bone marrow. Women experience chronic pain more than males – doesn’t it seem plausible that the underlying processes may differ? Thanks to protections for human subjects in research, animal studies and use of translation are necessary to better understand the cellular level activities, but understanding the limitations of the work is also vital. I have a new appreciation for the value of rigorous research methods. 

Also in 2017, Dr. Melissa Farmer, Clinical Psychologist and Co-Founder/CEO of Aivo Health, shared her work based on animal models she created to represent some of the patients she had treated.  She talks about memory: the capacity to encode, store, retain, and recall information and engrams: the brain's physical changes that represent a memory. Memories induce changes in your brain and this doesn't occur in a single location, but rather it exists in a network throughout the brain. When you think back to a moment that makes you very happy, perhaps you can link together what you saw, the sensations on your skin, smells and sounds and even how you felt, all different brain areas mapped together from that event. You can also have these memory maps for pain. She described synaptic efficacy: a nervous system pathway becomes more efficient at transmitting information when it is repeated, so in the case of a person experiencing chronic pain, the brain pathways are being used repeatedly and become more efficient at experiencing pain. Memories are based on learning and she also describes a key retention window within the four hours following education where there is opportunity to enhance memory through various approaches such as caffeine or incorporating multiple senses. Her presentation also illuminates research from Dr. Apkurian's (below) lab indicating how the limbic system, the brain’s emotion center, is involved in chronic pain. Dr. Farmer demonstrates how fear can create a memory that can be reversed through training via a dramatic video of a patient overcoming his fear of tarantulas.  

Stages for Chronic Pain

Dr. Farmer works with Dr. Apkurian. In 2018, Physiologist  Dr. A. Vania Apkurian shared his research on the underlying genetic predisposition for chronic pain that can be activated by injury. This slide from his presentation shows that some patients have a genetic predisposition to chronic pain related to their limbic system that, when triggered by injury, would induce transition from acute to chronic pain. The limbic system is the "older" part of the brain which houses behavior and emotion - and this bridges research between animals and humans as mice show these limbic system changes with pain, too. Acute pain is different from chronic pain in the brain. The brain re-organizes when chronic pain occurs, specifically with cortical and emotional changes and these may be partially reversible. The brain changes appear to imitate patterns seen with addictions and may indicate that a person experiencing chronic pain is addicted to nociception: the sensory nervous system's reception of stimuli which are capable of inducing pain.

The 2019 Keynote Speech by Dr. Antonio Damasio, a Neuroscientist at University of Southern California was a great talk about emotions and feelings and how animals have emotive processes but not all animals possess a mind to experience the consequences of feeling those processes. Thanks to Google helping me better understand the terms with an article that quotes Dr. Damasio, emotion: "a brief episode of coordinated brain, autonomic, and behavioral changes that evoke a response to an event; these are a lower level response." and feelings: a higher level response which provide a mental and perceptual representation of what is physically happening inside our bodies."

His talk brings us farther away from animals and into the human experience of feelings and pain. He states, "All living creatures exist, act, and behave... all living creatures share the imperative of regulating their life processes (homeostasis) such that life can persist, flourish, and project itself into the future..." In some (single cell) animals, the nervous system is not necessary for homeostasis where endocrine, immune, and circulatory systems are sufficient. Many sea creatures do not have brains and are still capable of survival. Animals regulated life long before the nervous system evolved but once you have a nervous system, you can have a mind and regulate life in a novel (and better) way.  The nervous system allows us to be conscious of behaviors, provides a mind that analyzes emotions to interpret feelings as good or bad. I think I particularly connected to Dr. Damasio's talk because of his explanations for the physiological underlying features of how we have pain from emotions such as grief.  When a loss occurs, there are internal physiological processes (just like if you were physically injured) that occur and which can be expressed as pain. 

Brain regions in emotions, pain, and pleasure

Dr. Damasio shares these anatomy images of the subcortical brain and describes the role of various structures in emotions and also production of pleasure or pain. I already discussed that there is an emotional component to pain involving the limbic system - and the amygdala is part of that system, responsible for fear and involved in pain. The nucleus accumbens is involved with pleasure. And the hypothalamus runs the endocrine system which interacts with the other components. As we need a mind to have feelings, we also need it to have pain as it is an experience, not an anatomical feature of the body. 

Pain Management 

IASP Pain Classification Guidelines

Moving more into pain mechanisms and management  is the 2021 talk by Dr. Annie O’Connor, Founder of A World of Hurt, discussing nociception and pain classifications.  She shared the IASP Pain Classification Guidelines which are referred to in the more recent Summits as the definition of pain was updated in 2020. This paper, written by a task force including Dr. Mogil (above), and Dr. Kathleen Sluka (see part three of this series) describes the changes made from the 1979 definition to 2020 with important notes that clarify meaning. These categories of pain: nociceptive, nociplastic, and neuropathic pain are further discussed in part two of this blog series and are mentioned in several Pain Summit Presentations.  Having classifications for patients based on their underlying pain mechanisms is a fundamental start to pain management. 

So much science! Sorry, but I'm not sorry for rambling about all this amazingness.  I've always enjoyed using my blog as a place for me to organize my thoughts and what I'm learning and this was just such a huge undertaking… hence, three parts! I’m personally fascinated by the neuroscientists, and even more-so, I'm amazed by their knowledge and their willingness to share where the limits of our science exist.  Each talk includes a Q&A session and there were multiple questions where the research hasn't been done in that area yet and so the answers were unknown. That's really refreshing and demonstrates how (relatively) new a lot of this understanding is and why it's important for clinicians to learn and understand it more.  Interestingly, I don't really find this information to be very useful for my patients, particularly because most of my patients are teenagers. Even if they were adults, I'm not sure they would need to understand this to help improve their pain or quality of life. So how can I apply this knowledge to help patients feel better? Numerous therapeutic approaches have also been discussed throughout the Summits, and I won’t include them all here, but I will point out the ones that resonated most with me and which more directly impact my own patient care. 

New Zealand Occupational Therapist Dr. Bronnie Lenox Thompson’s 2016 talk described Motivational Interviewing (MI) as a communication structure for patient care to be a partnership based on clinicians guiding patients with compassion and by evoking motivation for them to pursue their own goals. She includes three related concepts: cognitive dissonance: inner drive to hold all of our beliefs in harmony, but when a patient's beliefs are contrary to our beliefs, we may have to act in a way that opposes what we believe. This is a conflict in our own thought practices as we think but act in opposing ways. Self perception theory: we like to behave according to what we say and believe. In this theory, our emotions are related to our actions and behaviors.  Interpersonal warmth: being a nice, warm, supportive, listening person to encourage others to go along with what we say.  With these concepts in mind, giving your patient autonomy in deciding how to improve their condition considering your guidance is an ideal therapeutic alliance approach. 

Alison Sim demonstrates CBT

In another 2016 talk that considers communication and a psychologically informed approach, Australian Osteopath Alison Sim presented about Cognitive Behavioral Therapy.  She uses a great example of burnt toast to demonstrate the different ways a person could react to this event with different thoughts, emotions, and behaviors.  In the first scenario, the person burns toast, thinks "bummer!" and maybe feels indifferent, following with the behavior of toasting another slice of bread.  As the emotions and thoughts escalate to more negative, you reach the final scenario where the toast is burnt, the thoughts are "even the toaster has it out for me" and the emotions are angry with behavior kicking the cat. (I think we're talking about feelings rather than emotions, here, but I'm not here to pick it apart.) Patients who are more distressed and disabled may need a more intensive program than CBT, so she reminds us to match our treatments to the patient in front of us. I just received Alison's book "Pain Heroes" and am looking forward to reading it!  

Social Communication Model of Pain

I'm a physical therapist who STRONGLY believes that the words we use with our patients matter and that communication and therapeutic alliance are essential skills for optimal care. I particularly liked this quote from Physical Therapist and University of Florida Clinical Associate Professor Dr. Joel Bialosky’s 2022 presentation quoting Wambold 2017, “Some therapists consistently achieve better outcomes with patients than other therapists – and these differences are not due to random error, patient characteristics, or other systematic sources of error.” The amount of an observed outcome is attributed to something inherent to the therapist. Therapeutic Alliance is repeatedly mentioned in talks.  It comes up in Physio, Consultant, and Mentor Dr. Devra Joy Sheldon's 2020 talk along with the Social Communication Model of Pain, reminding us of the importance of social contributors to reduce shame in pain management and that we are inextricably linked to our patients' pain experiences. Also in 2022, David Poulter presents his talk about therapeutic alliance and patient-centered care, which come up in several other talks over the years and repeatedly reinforces the importance of clinician and patient relationships. He reminds us that We need to change before our patients can change. 

You may notice that nothing I've mentioned has been physical yet. And I'm a physical therapist. The Pain Summit includes occupational therapists, massage therapists, chiropractors, mental health providers, physicians, and patients as attendees, so the talks cover many different perspectives.  All the providers would need to move beyond communication and into their specialized interventions.  In 2017, Cor-Kinetic Owner and Physio Ben Cormack from London talked about exercise and movement. The numerous benefits of exercise - like improved respiration and cardiovascular endurance, increased strength, and reduction in pain, are all discussed. He describes the need to guide patients so they transfer from an external to an internal locus of control and help them to form new memories that are positive instead of the negative pain memories they've associated with movement. In 2018, Canadian Biomechanist, Physio, Chiro, and Strength and Conditioning Specialist Greg Lehman shared "When Biomechanics Doesn't Matter." These guys are really great presenters, but it's probably harder to make neuroscience funny where it's a bit easier to make exercise a bit comical.  Both of them demonstrate that specific exercises like the ones we frequently provide in physical therapy practice aren’t the necessary target for intervention – but more so getting patients to participate in the activities that bring them joy is a more optimal approach. I've previously written about Dr. Lehman's "Reconciling Pain Science and Biomechanics" course and here he negates numerous concepts learned in PT School about movement patterns and biomechanics that research does not support. It’s not that form and posture and movement patterns never matter, it’s just that for the general population, most of the time it is unlikely to be the driver of pain.  So yes, exercise is helpful for management of chronic pain.  The exercise probably doesn't need to be specific and is one piece of a more complicated puzzle. 

Body-Wide Symptoms of Long Covid

Which brings me to the special topics. I think these are really important and deserve far more attention than I’m providing here, but for my 12 subscribers to this blog, they’re key considerations for patient care. First, the 2022 talk by Physio and Athletic Trainer Dr. Daria Oller and also presentation from Physio and Professor at University of the Pacific Dr. Todd Davenport regarding Long Covid, Post Exertional Malaise, Myalgic Encephalitis, Autonomic Dysfunction, and Chronic Fatigue Syndrome are essential viewing for anyone treating patients with these diagnoses.  Dr. Oller and Dr. Davenport are both involved in Long Covid Physio which is an incredible resource for patients and clinicians. Our typical approach using progressive overload exercise for patient care is contraindicated for these patients and we need to spread the word that a pacing approach is indicated, otherwise you are doing harm.  It’s incredibly likely that if you are a physical therapist, you’re going to have a patient with post viral illness or chronic fatigue, even if it isn't Long Covid.  Take the time to watch these talks so you can be better informed.

And last, but very certainly not least, I encourage all healthcare providers to watch the 2022 talk from Dr. Lisa VanHoose entitled "Your Pain Evaluation Is Incomplete Without a Zip Code Assessment." where she goes into great detail about your personal biases and how zip code data can give you a lot of context and is easy to get.  This link (after you scroll down to "Discover the Power of Data") gives you the chance to enter a zip code and see numerous data points including household income, cost for medical insurance, how many people live in that neighborhood, diversity, and demographics. The data will be presented as averages and needs to be confirmed along with the story from the patient in front of you.  Understand that two patients could live a mile away from each other, and one have limited access to medical care, physicians, pharmacies, schools, green spaces, public transportation, grocery stores, and more – all of which impact their lived experienced and their health.  If you can't watch the full hour of her talk or you're not convinced, here's the five minute video "A tale of two zip codes" Dr. VanHoose shared that starts you thinking.  I found this talk eye opening and highly recommend it.

There were so many additional excellent speakers, many of whom I’ve gotten to know in some capacity, others who are juggernauts in the field. Some of the topics, such as pelvic health, are incredibly important but are a very small percentage of my patient population, so I couldn't relay the important pieces from those talks in a way that would help others. If you're working with patients experiencing chronic pelvic pain, I highly encourage you to go to the Pain Summit YouTube Page and check out the videos there. Other talks stood alone like the presentation from Dr. Sandy Hilton and Dr. Mark Milligan on clinician burnout, which is a really important topic and relevant, but is less specific to patient care.  I had to draw a few lines, and it left out amazing speakers. I’m sorry to leave everyone else out of this post.  Your work and your knowledge have impacted me, and I’m so grateful.  

Stay tuned for Part Two coming soon!

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!