Cracking Concussions: Part 2

Concussions really do make a lasting impact (pun totally intended) on an athlete’s long term function. In case you missed last week’s post about my own experience with concussion, check it out here.

In the event that you already caught Part 1 or just want to learn more about the impact of concussion, check out this blog honoring one of my first posts from this blog’s birthday, just in time (early this time!) for #throwbackthursday. Let’s face it, if I don’t post it today on Wednesday, I’m going to forget to post it. What are you doing to raise your or others’ awareness of concussion in your sport or your child’s sport?

youthsportspt

Concussion-Cartoon Photo credit: http://iphysioperth.com.au/news/sports-physiotherapy-for-common-athletics-injuries/

If you’re just picking up this post, you may have missed the story from Part 1 about my recent patient (Patient 1) who presented with a concussion. I discussed how without my recognition of his symptoms, he may have been misdiagnosed and/or mismanaged.

Mirror this case with another case of a high school athlete (Patient 2) I was treating at the exact same time of Patient 1. Patient 2 sustained a head injury when falling backward onto her head during a home plate collision during a softball game. Her father, a pediatric physician assistant, was on the scene and immediately recognized signs of a concussion. She was monitored and taken to a local emergency department. She followed up within a day or so with a pediatric primary care sports medicine physician, who recommended cognitive rest, a modified school schedule and program, and prompt referral to physical…

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Help! My kid is in pain! What does this mean? (Part 1)

I’d be willing to bet that you generally don’t like to be in pain. I’d be willing to bet more that you really don’t like it when kids and teens are in pain. Chances are, if you are the parent of a young athlete, your child or teen has been in pain at some point in their sports “career.” Maybe you knew what to do about it and your child got better without any problems. Maybe you had no clue and turned to your friends, Dr. Google, or relied on your own steadfast remedy system.

I’ve encountered a gazillion parents who fall all over the map of knowing how best to care for their children’s pain. Sometimes parents make decisions about how to care for a child’s pain that ultimately leads to worsening of the problem. These decisions may be based on an interest to keep a child playing a sport for a number of reasons. On the other hand, some parents fall more into the “hypervigilant” category. These are the parents who fast track their children to the urgent care center every time Johnny or Sarah complains of an ache or pain.

hello kitty band aid

Hello kitty can sometimes make everything better

Despite a parent’s style in caring for pain, one thing all of these parents have in common is that they mean well, regardless of which way they handle each situation. Culture and experience lead people to act in different ways, but there are a few constants that hold true in caring for a child or teen’s pain regardless of one’s background.

Given that I happen to work with young athletes of all ages, I often get questions from patients, colleagues, friends, and family members about pain in their own or their friends’ children. Here is a sampling of the questions I am asked quite frequently:

  • “My 12 year old has been having ankle pain off and on for 3 weeks. She’s been wearing a brace and keeps doing her sport but she says it’s getting worse. When should I panic and do something about it?”
  • “My 8 year old just fell off the monkey bars, says his elbow hurts, and refuses to move his arm. I have 3 meetings I need to attend and he has a baseball game tonight. Can we wait and see how it feels tomorrow?”
  • “My 15 year old’s back has been hurting for 6 months and it’s getting worse. She has bad posture. I told her to stretch and do some yoga with me since that’s what helped me. We also put her on our home traction table, I let her use my TENS unit, and she’s been getting chiropractic adjustments from my chiropractor 3 times per week.”
  • “My friend’s 13 year old has mysterious abdominal pain and has been out of school for 6 months. Nobody can figure out what is wrong with her. Is there another specialist she should see or is this all in her head?”
  • “My 17 year old has hip and groin pain. I think it’s a hip flexor injury. She just needs to stretch her hip flexors and do some Pilates, right? Can you show me some stretches for her to do?”

<Spoiler alert: If any of these situations sound familiar, you’re not alone! We will revisit each of these situations—and what to do about them– in a future blog. Stay tuned!>

Parents, friends, coaches, and kids and teens themselves have lots of questions about how to deal with pain. This can be very confusing, and everyone has an opinion on it. Before we address the somewhat confusing question of how to deal with it or what to do about it, we must first address the possibly more confusing topics of what pain is and what this could mean in a kid or teen.

Defining Pain

The first thing we need to do is define pain. Get ready for a blast back through science class. A person can perceive and experience pain for any number of reasons. According to the International Association for the Study of Pain, Pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” What that means is there is not always damage somewhere in the body when pain is present. If that’s the first time you’ve heard that, you’re not alone. What we know about pain barely scratches the surface of what lies beneath the understanding of why it occurs.

Pain is an output from the brain

pain bucket

Pain is an output and sum of all the things that happen to us!

 One thing we do know is that pain is absolutely, positively, 100 percent produced as an output from your brain. See this great youtube video to explain this. While the video is about chronic pain, the same concept applies to just about any type of pain.

Think of the body like an email communication system. You bump your knee, and your ultra-fast email system sends a message through your nervous system to a part of your brain that acts as a switchboard. The switchboard decides if the message is relevant and if it merits being sent on to any other part of the brain. What you need to know about the switchboard is it is not in the conscious part of your brain. If the switchboard deems the message relevant, it sends the message along to your cerebral cortex. This is the part of your brain where you make thoughts, perceptions, and do all the cool, complex processing that makes us human. It’s not until the email message gets to your cortex that your body then decides “oh wow! Bumping my knee hurts!” Thus, it is an output, or a decision, just like any other decision you make.

PainKillers

That pink spot in the middle (the thalamus) is the switchboard. The thalamus intercepts and interprets almost every signal that comes into your brain. This includes stuff like smells, tastes, sounds, thoughts, and signals from organs you may not even know exist!

Now you may be thinking here “Ok Julie, I didn’t decide that I wanted to be in pain.” That’s right. You didn’t. But your conscious brain did. Due to wiring in your brain that you’ve been formulating since before birth-your brain decided whether or not that knee bump was going to be painful. The combination of your life history, culture, environment, previous experience, previous pain and injury, overall health status, emotional status, and many more factors – things that you sense and direct every day—was responsible for deciding if that bumped knee was going to hurt or, well, just feel like you bumped your knee.

painbucket

You can think of pain in a kid like a wheel–it’s totally dependent on so many factors. These factors include intrinsic ones (stuff within the kid that can’t change, regardless of what is going on around the kid), and extrinsic factors (stuff that can change–IE the environmental factors going on around the kid).

 Notice that I said perception of pain is based on factors like life experience, previous pain and injury, and emotional status. Those are just a few factors that might make pain perception a little different in kids. Why is that? Kids have less life experience, likely fewer pains and injuries, and emotional and cognitive/thinking statuses that are not fully developed. This makes pain perception very different for them.

If things are going well, most kids experience the occasional bump, bruise, scrape, splinter, or “owie” as my 21-month-old niece likes to call it. Most “kid pain” gets better with a kiss from mom and dad, maybe a band-aid, and encouragement to “shake it off.” Healthy kids without serious problems are often seen to be running, jumping, and playing through pain. It’s not until pain slows them down or changes their behavior that it usually registers on parents’ or coaches’ radars.

pain experience

What this means is that as kids develop, they may not know exactly what is going on with their pain. They often don’t have the experience or previous pain and injury to be able to describe it. This can make it hard for parents, coaches, and healthcare providers to understand how to help them.

Oftentimes kids learn how to describe pain based on what an adult tells them it should feel like. Case in point: I’ve had an 11-year-old tell me that her knee feels like “bone on bone.” In actuality, this is how physicians or patients may describe an extremely arthritic joint in someone who is a middle-aged adult and has lost all cartilage cushioning in the joint. While not impossible, it’s not something that we would typically expect a ‘tween to say. Ask a 7 year old to describe the pain and they will give you a blank stare. They just don’t have the experience, the complex thinking processes, or the knowledge to know how to describe it. Typically they will just agree with whatever an adult says.

Not only do we have the challenge of getting kids to describe what’s going on, but kids’ behavior around pain is also all over the map. Depending on influence from adults, siblings, and friends who may have pain or have loved ones in pain, kids learn how to behave and perceive pain from those around them. Some kids learn from a very young age that pain is scary. They may panic or complain constantly about every ache and pain. They may also learn that being in pain is a way to get support, attention, or avoid an unwanted activity. This would mean the real underlying problem may not actually be related to the pain at all (more on that later).

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Other kids may learn that “being tough” while in pain is admirable and brave. These kids may not complain at all when they probably should be. This means you may have one kid who has a total meltdown over a splinter, and another kid who seems calm and collected over a broken leg. As you may imagine, there’s clearly a fine line to walk here in teaching kids and teens how to cope with pain. We don’t want to panic them, and we don’t want them to be heroic at the expense of hurting themselves more. And even if you think you’re toeing that line just right as a parent or coach, chances are they’re learning about pain coping (and everything else kids, ‘tweens and teens learn) from other outside influences, too.

Needless to say—pain is complex in any person, regardless of age. Add a developing brain, body, and lots of family and sports influence in the young athlete—and we have the potential of launching those complexities to exponential levels.

conquering child's chronic pain

Here’s a great book by Lonnie Zeltzer, MD. It’s technically about chronic pain—but keep in mind “chronic” in a kid could be 2 weeks. It’s a much smaller percentage of the length of their life. These same concepts can apply to kids and teens of all ages, and even those in acute (IE, just happened JUST now) pain.

WHy do I hurt

This book: Why Do I Hurt? by Adriaan Louw, is appropriate for middle schoolers, high schoolers, and college students. It is written on the patient’s level and really explains pain in a way that fosters understanding. Great for parents and coaches too!

 

Now that you’re armed with more knowledge than you ever wanted to have about what pain is and what it means in a child, teen, or young adult, you’re probably asking–So what do we do about it?

Stay tuned for Part 2 to learn how to address and cope with a child, ‘tween’s, teen’s, or young adult’s pain situation.

Are you the parent of a young female athlete? 10 things to know right now

Female athletes have a million awesome attributes that make us way cooler than boys. Girls rule and boys drool, right?

Even though we are sugarier (word invention), spicier, and everything nicer than our male counterparts, we have some unique considerations to worry over that sometimes make being a female athlete a challenge.

Maybe you were a female athlete from a young age. Think back to your first competition, meet, match, or game. For me, it was at age 6 in a summer league swim meet. I fell in love with the sport and the rest was history.

Dedicated to my sport, I raced through the rankings and ended up training 8-9 practices per week by 8th grade. Little did I know that the 2 fractures I had as a teenager were warning signs of a potentially bigger problem. Yikes. And little did I know that the “mental slump” I was in during high school and the depression that set in when I could not swim after shoulder surgery in college might catch up to me later.

How annoying is it that I can look back and see so many of these warning signs for things that became bigger issues later? How much more annoying is it that there’s nothing I can do with my current knowledge and skills to go back and help young athlete Julie? I guess that’s why I dedicate my career to doing that for everyone else.

If only it were that easy.

Parents and athletes often resist or fight against the education I so eagerly want to provide them and—perhaps most notably—that they are paying me to give them. I regularly hear or encounter phrases like these. Maybe you’ve heard them too, or said them yourself:

“Oh, that couldn’t possibly apply to my daughter”

“Injuries and burnout are ‘normal’ and expected for this particular sport”

“Of course she loves the sport! Look at how well she is doing!”

“She couldn’t possibly take time off or give up the sport. It’s the only thing we have getting her into college!”

I had a meeting with an awesome pediatric/adolescent sports medicine physician this morning and we commiserated over these phrases we so often hear, in addition to several other topics that young female athletes and parents just don’t love to discuss or address—but so desperately need to.

Yeah ok, I get it. Your daughter is flawless and invincible. She is actually an exception to the rules, statistics, and science behind health and wellness in young female athletes. And this is because of her natural talent and passion and of all the money and time you put into allowing her to succeed, right?

I will never fault a parent or loved one for doing what they think is the right thing to do. Most or all of these phrases and thought processes are 100 percent uttered out of caring, good intention, and well meaning. But sometimes—just sometimes—it’s possible people just don’t know any better. That’s what those of us who have personally been there as the athlete, and who now work in this field, are here to help you understand.

baseball should be fun

Regardless of what you believe or support, what we can all agree upon is that no parent or athlete has a crystal ball. None of us in the medical and sports medicine world can predict the future, either. BUT-we do have a little bit more gypsy skill than meets the eye. We can look back and use our clinical judgment to determine what types of behaviors and movements might lead to a problem in the future. And great news!!! We’re actually on your side! We want to help you and your daughter succeed! So just read and listen for a few minutes. Here are some key points you should know about how you can help her too.

  1. It’s not about you

This should go without saying, but unfortunately, I’m finding I still have to say it. This means it’s a real issue out there, folks. Susie’s gymnastics competition may, in fact, be a fashion competition for moms. You are convinced the only way for your 5 year old all star cheerleader will win a national championship is with her belly hanging out, 5 pounds of makeup and bling, and hair extensions. Maybe there’s an unwritten competition for which family provides the best, most organic, gluten free, Pinterest-worthy snacks after the baseball game. Or maybe you’re sure your 6th grader is going to be the next basketball star, just like you were in college. This means you have to be at every practice, on the edge of your seat, letting your blood pressure go through the roof and finding all the flaws in the referee calls because some other kid just outscored your kid. I get it. You mean well. And these are real things that actually happen. It’s likely that as parents, you get caught up in them. That’s fine. But do your daughter a favor: keep the attitudes and the behaviors to yourself. You may not realize it but she is watching you. Chances are, she is internalizing how YOU feel about her sport, and this could eventually backfire. Make her sport all about her.

baseball snack

Photo credit: Pinterest

  1. Milk: it does a body good

Disclaimer: Dairy allergies and sensitivities are real. I respect that. This is not actually about milk, but I needed something catchy to get your attention. Did you know that almost all of a young female’s bone health is built and stored before she reaches her 20’s? Flash back to teen Julie and her stress fractures. Did you know that the biggest risk for a stress fracture is a prior history of fracture? Bummer for me and my 30-something bones now. That’s what my allergist meant when she told me that being on inhaled steroids as a teen with asthma and participating in non-weight bearing exercise could adversely affect my bones. How are you ensuring that your daughter is getting the right amount of calcium, and the essential vitamin D to help her body absorb the calcium and build strong bones? Maybe let her play outside in the sun a little—with adequate sun protection but not so much that she doesn’t get the natural healthy effects of sun exposure. And maybe let her have that fro yo she’s been begging you for.

  1. Don’t be afraid to discuss menstruation. Period.

You wouldn’t believe how many people I freak out when I ask them about menstrual history. What’s the deal here people? You are female. You are over age 9 or 10. It’s part of your life, or soon to be part of it. So much a part of your life—that if it is NOT happening—we have some reasons to be majorly concerned. So let’s talk about it! While the age of menarche-the onset of menstruation-varies widely from girl to girl, it’s important as parents and medical providers to be having conversations about it BEFORE it’s time for her to begin menstruating. Why? Did you know that being an active female affects estrogen and progesterone levels and exercise in excess can lead to irregular menstrual cycles? Add on stress, rigors of school, and possibly inadequate nutrition: and those young girls’ periods are at risk of being jeopardized. Problems with hormone fluctuation are often seen by young girls in certain sports as “cool”–as in–you’re not cool unless you’re skipping periods. Why are they learning this and from whom did they learn it? Sure, not having to deal with the hassle each month sounds awfully appealing from time to time. However, knowing the lasting effects this phenomenon has on reproductive, bone, endocrine, mental, and physical health is important. We need to teach each girl that menstrual irregularity is just as concerning as discovering a bad zit on her chin the morning of school pictures.

  1. She CAN be a Disney Princess: preferably Sleeping Beauty

Why are girls skipping periods? There are lots of reasons. One of them is too much energy spent for the amount of rest provided. This is called a RED-S, or relative energy deficiency in sport. You may have heard of this concept referred to as the Female Athlete Triad before. It’s all about energy. Energy is a math problem (sorry if you hate math). It is the sum of rest (physical, mental, and emotional) and nutrition minus the energy lost during exercise and daily life. See the equation:

Energy = (Rest (physical, mental, emotional) + Nutrition/Calorie Intake) – Caloric Expenditure (energy lost during exercise/daily activity/metabolic activity)

The body is smart. If energy is lacking, it will steal it from the energy used to do other things, notably that which is used to produce hormones and run the reproductive system. You may think “Susie is not going to reproduce for another 15-25 years, what’s the big deal? Hello! This is NO BUENO people! Lack of estrogen has a strong correlation to later infertility, poor bone health (read: osteoporosis), in addition to problems with the adrenals (stress hormone producers). She needs those stress hormones to build adrenaline, stay awake in school, take an exam, and participate in her sport! This can have a dramatic effect on her later in life. So for that young female who is practicing 40 hours per week, she needs to get just as much energy input through nutrition (see point below), but also through sleep. To add insult to injury—she probably isn’t sleeping as much for education and social reasons. Isn’t it every kid’s dream to stay up late? That’s a normal part of childhood/teen rebellion. Not to mention she may be up all night doing homework for her 37 AP classes and SAT/ACT/MCAT prep classes (MCAT? Isn’t that an exam for college students? Of course it is! But Susie will start studying at 14 for it!) If she truly loves her sport, she needs to learn that sleep will help her jump higher, run faster, and shoot better. And help her make her 4.5 GPA and ace the MCAT. Sleep hygiene is a habit to address when she is 6, not when she is 26 and running ragged in medical residency.

  1. The drama llama: Kid problems are REAL problems

For the next paragraph, we’ll completely flip the situation and blame little Susie for all of her problems. This means you’re off the hook mom & dad, right? Wrong. Susie’s brain is NOT like yours, mine, or her older college age brother’s. This means that it is completely normal for her to be a dramatic, rollercoaster riding, irrational and emotional kid/teen. Why? Because she is a growing kid/ teen and we can’t stop that! The female brain processes and responds to information very differently than the male brain. In addition, she’s growing. Just because she is good at her sport and makes good grades, that does not mean her developing brain is equipped to handle the real problems of childhood, ‘tween-hood, and teenage life. You know what I’m talking about here: how that swimsuit looks on spring break, who she will dance with at the 7th grade dance, if she will try beer at the 9th grade birthday party (or if she will get invited), how many instagram “likes” and emoji tag-backs she got yesterday, and how to talk to YOU (her parents) about the fears and anxieties she faces as a young woman, including her opinion on how you parent her. Those are the real problems that often preoccupy her mind and affect her performance in her sport and her schoolwork. Plenty of scientific evidence supports the fact that a young female’s brain does not fully develop emotionally and cognitively (IE, the ability to feel, think and process) until her mid-20’s. She cannot process, communicate, and understand things the same way you and I do. And even then, some brains never develop those skills. Every girl needs a valuable mentor to help her navigate through all of her perceived life-or-death problems. Make sure she has that.

  1. The apple does not fall far from the tree

Speaking of role models, it’s important to remember the old adage I wrote above. Girls learn how to act from their parents. If you’re a 2 times-a-day gym rat, she will think that is normal and the right thing to do. If you eat the whole box of Samoas while stressing over the girl drama you face at work, what do you think she will do when she is faced with drama among her peers? What happens if you are the overachieving parent who fills his or her plate with 300 (Well-meaning) activities with little down time? What do you think she will do with her spare time? Fill it! Some of the biggest predictors of problems in young girls are the problems faced by their parents. These could be medical, social, emotional, or financial problems. That is not anything to be afraid of. It’s important to be aware of your own vulnerabilities, acknowledge them and most importantly-model that you are taking a stand to take care of them yourself. If you take care of yourself, she will be taken care of too.

Credit: http://1.bp.blogspot.com/_Mn5Un4rHQlk/TEBkIdwVK_I/AAAAAAAAAtM/_0Qd01jV7Ds/s1600/appletreecp.gif

  1. You are what you eat

I’ve already touched on this several times throughout this post. An athlete is only as good as the fuel she provides for her body. My colleague Mandy says “You wouldn’t try and drive across the country without putting gas in your tank and checking your oil, would you?” The same goes for the body. Most athletes and their families underestimate how many calories they burn throughout the day in addition to during a sport. This means they also underestimate just how many calories they need to be taking in. It’s all about energy availability for a healthy athlete. Consult a pediatrician and sports dietician for the best advice.

  1. Variety is the spice of life

Believe it or not, Susie likely has interests outside of horseback riding. She may have her room decorated with posters of horses, ribbons, and ask for a horseshoe-shaped birthday cake. Problem is, she may not know what those interests actually are. Why? Let’s pretend she began to specialize in equestrian at age 8. She was so good at it that it’s all she wanted to do. You’re thinking “I just want her to be happy and do what she loves” and maybe “sweet! College scholarship in the making,” so naturally, you reinforce this behavior. Why wouldn’t or shouldn’t you, after all, that is good parenting. I agree. There is more to it, though. What happens when Susie gets hurt at age 13 and can’t ride for a few months? Maybe she has school to fall back on. But maybe not. Equestrian has been so rooted in her identity that she may begin to experience symptoms of anxiety and depression when she cannot participate. She has no idea who she is or how to define her successes and failures. Everything feels like a failure if it’s not equestrian. Compound that with the fact that she may have been so dedicated to her sport that she cannot identify several other interests to keep her busy, and you now have a snowball effect. As adults, we know that this does not make logical sense. However, to a teen-this can be world ending for them. We have to protect them and give them skills and mentoring to honor themselves and their passions-whatever those may be. Girls don’t have to be the all star at 50 different activities, but it’s important to have other activities on which to fall back. After all, remember that when she is an adult, she may not have the time or money to ride horses anymore. Make sure she has other things to keep her engaged and enthusiastic about life. It will pay off in the long run.

  1. No pain no gain

Ah, finally. A moment to write about the “PT” part of this post. Playing through pain and injury is not, I repeat, is NOT admirable! With the exception of Kerri Strug in the 1996 Olympics, nobody is going to look back on their life as a young athlete and say “wow! I am so glad I played on that sprained ankle! Look at all the fame and admiration it brought me.” Pain in a young athlete is most often not anything majorly serious, but it is a sign that something is going awry in how they are moving, that they are not getting enough rest, or that their tissues are not able to heal. This means those same tissues will not help them perform as well. Their performance will suffer.  Pain is not just “growing pains” that they will “grow out of.” A brace and some KT tape will not fix the problem. At a very minimum, get them checked by a pediatric/adolescent sports medicine physical therapist or physician and make sure you’re not ignoring an issue that could rear its ugly head months or years down the line. The small investment in time and money doing that for your young female athlete will make a world of difference in the repercussions it may cost her later.

If your kid gets through sports with all sorts of colorful adornments you picked up at the local CVS, it's probably time to call a medical provider.

If your kid gets through sports with all sorts of colorful adornments you picked up at the local CVS, it’s probably time to call a medical provider.

  1. Have a Plan B, C, and D

Lastly—college scholarships, professional sports, or whatever end game result you’re looking for may not ultimately happen. There are thousands of reasons that it could all work out, and thousands more that it may not. It’s important for every young athlete to have an adult facilitate for them a plan B, C, and/or D. It’s important to be active and healthy (the repercussions of not being active are far worse), but it’s important to balance that with being a kid, being healthy, and going about it the right way. Nobody is perfect. Even if you followed all of this advice (which, admittedly, is far from comprehensive), something still may go wrong. Be there for her when it does and help her unleash her plan B.

In summary:

You may have noticed a habit or behavior you’ve done at some point along the way–either to yourself or your young athlete. We’ve all done them! That’s ok! Nobody is perfect, and nobody has all of the answers. But now that you’re armed with some information and tools, you can start to pave the way to a healthy, successful, athletic life for your young female athlete. These things are arguably more important than any practice, costume, Pinterest snack, hair extensions, or $400 swimsuit you could possibly provide. That’s what we call “sponsoring” your athlete. Nike is a sponsor to sports teams and provides all of those things-but you better believe they don’t consider themselves parents of the same athletes. Girls need your awesome sponsorship, but also your awesome parenting skills. This means support, guidance, and unconditional love regardless of how well they perform or how much they truly love their sports. It’s our job as grown-ups to give that to them–and most importantly, ensure that the number one priority for all athletes is that they are having fun.

The Road to TED Talk-ing

CSM2015Marquee_960x222ted-main-stage

After watching my Duke Blue Devils conquer the ACC Women’s Swimming Championship at Georgia Tech this weekend, I spent the better part of my weekend devouring some great TED talks. Not only were the messages by Shirzad Chamine and Brene Brown inspiring and refreshing, but they also gave me the opportunity to reflect on my own recent public speaking experiences.

Two weeks ago, I had the honor and privilege to do what I consider two of the most humbling experiences of my professional life: speak with and in front of colleagues at the American Physical Therapy Association’s (APTA) Combined Sections Meeting. In keeping with the fact that it occurred the same week as the Super Bowl-we’ll  basically equate this to the Super Bowl of all PT nerd-dom, complete with fanfare, its own hashtag, an exhibit hall with plenty of games and freebies, and plenty of evening parties. Just imagine 10-15,000 of your best nerdy PT friends all descending on one giant convention center in snowy, frigid Indianapolis (seriously, whose idea was that?). It was a geek fest- but a very inspiring geek fest at that. And some may argue it offered some great people watching and fashion critiques. Apparently the token wardrobe for PTs is still believed to be khakis and polos, if you were wondering (there is an entire Twitter conversation about that).

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They even decorated the stairs with nerdy PT-isms

I found out last summer that I would be speaking, so there was plenty of time to prepare. Like the athlete that I am, I spent weeks training, rehearsing, polishing, and preparing my presentations so that I could get up there and deliver the presentations in true TED talk style. I read a book, watched tons of TED talks, and ran the talks by several colleagues and students. I selected outfits that would convey my personality. People: I wore HEELS for crying out loud. I spent hours in the convention center’s “practice room” making sure that the computer and projector were compatible and that all of my photos and videos shone through to convey my visual message. An audiovisual snafu was a worst nightmare for this overprepared, overachieving, nerdy PT.

Completely relaxed and confident, I walked into presentation 1, plugged in my computer for one final test, and it popped up beautifully onto the screen. I was speaking among 10 other experts in sports medicine. I was 7th in line to speak, covering a case study of a young female athlete swimmer (does it get anymore exciting for me!?). I sat listening to my colleagues share their stories, eagerly awaiting my turn to take the podium. It was finally my turn. I thought in my best Kevin McAlister homage “This is it, don’t get scared now,” proudly took the stage, and plugged in my computer.

Womp womp.

As Murphy’s Law would have it, all of those hours of preparation and practice came to a screeching halt. The A-V connection wasn’t working. What!? I’d practiced and tested it a minimum of 23495 times on this very projector! Why wasn’t it working? I had approximately 1 minute to get it sorted out before they told me to get off the stage and let the next speaker go. That 1 minute went pretty quickly and unsuccessfully, and off I went, sheepishly back into the audience.

Now, this could have been a total game changer. First time on a big stage and my computer malfunctions. The whole world can now seemingly assume that I wasn’t prepared. But…but..I practiced!! I swear! And I even bought the special Mac adapter! A charitable stranger offered up his PC computer and I spent 20 minutes transferring files, videos, and completely rewriting my talk. Apparently presentations written on a Mac don’t always transfer perfectly to a PC (Insert elitist Apple statement here). I finished everything just in the nick of time and retook the stage.

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Talk 1: The Long Term Effects of Slipped Capital Femoral Epiphysis (SCFE) in Young Female Swimmer, part of the Sports Section’s Complicated Patient Session

By this time, I was going last. Nearly half the room had emptied as people left early to catch lunch. It wasn’t what I had envisioned. But I charged on. To my surprise, I was even more relaxed this time around. I thought, I suppose it can’t get any worse… The projector worked, I didn’t even need to consult my notes, and I delivered the message with ease and grace—even inserting a little humor here and there. After the talk, I had some wonderful conversations with PTs and PT students who were so thankful for a talk about swimmers-a topic that is rarely covered in a sports medicine world heavily focused on more traditional sports.

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Thanks to the faithful who stuck around to see me dressed in a Missy Franklin costume!

First talk down. Snafus aside, I was pretty proud of myself. Now that I had ripped off the proverbial Band-aid, I was more than ready for the 2nd talk the next day.

For the next presentation, I was speaking with 2 of my most valued mentors and colleagues-Blair Green & Julie Wiebe. See this post and this post and this website to learn more about Blair. See this blog and website featured in my Blogroll to learn more about Julie W. Needless to say-they are both rock star PTs that I really admire, so it was a honor to stand up and speak with them.

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Here I am in Talk #2. Credit to Julie Wiebe for the awesome slide. Credit to Jen Miller for the photo.

I was up first. I joked that they were hazing me and made me go first and explain all the “sciency” concepts because I was the baby of the group. For the record-It is NOT easy to speak continuously for an hour! Talk #1 was only 9 minutes. This one took me 65 (apologies to Julie W for being long-winded…I blame the bad video connection!) The good part about having to teach a big group science concepts is I also got to exercise my inner 3rd grade teacher-meets-kids Pilates instructor. Getting a room of 100+ people on their feet and making them wiggle and do some silly things really does give an air of feeling powerful (or maybe that’s just what I’m telling myself).

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Audience on their feet, following directions. What fun!

We had a pretty awesome message to share, if I do say so myself. The presentation, Building the Female Athlete from the Inside Out, conveyed the most current ways to build and fashion a female athlete’s movement performance after injury or impairment. We took a multifaceted approach, covering three unique cases. I discussed a young female athlete (my wheelhouse!), Blair shared about a post-partum runner (her true love), and Julie W anchored the relay by taking on the beast of the CrossFit/High Impact athlete (seriously, she is the only person I know who can talk publicly about that hot topic and not get tomatoes thrown at her).

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Here I am with the Female Athlete Dream Team: Blair Green & Julie Wiebe. Fully representing The Georgia Bulldogs and Duke Blue Devils in our color scheme.

Of course, this presentation was not without its blessing from Sir Murphy and his law. While I had carefully ensured no encore performance of the computer issues I had in talk #1 (of course I had!), it turns out there were more issues to be had. This happened in the form of the presentation completely shutting down in the middle of Blair’s portion. <Cue potential panic attack>. Good news—turns out we could give the presentation in our sleep and she carried on and handled it like a champ while I scrambled to help her fix the problem.

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#nerdclub president takes the podium. Who cares if the presentation shuts down in the middle? No biggie.

Overall in that talk, we had our share of issues and imperfections. There was certainly a laundry list of things to improve upon in the future. Despite those things, the outpouring of support and gratitude following our presentation was humbling. We were tweeted, retweeted, facebooked, Pinned, emailed…the list goes on. As far as social media goes, we were definitely feeling the PT nerd love.

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I’ve sat in many talks tweeting stuff the presenter says. Now I’m the one being tweeted. #whoa #humility #carefulwhatyousay

But perhaps the most rewarding feedback we received was at the conclusion of the presentation. As the last presentation on the last day, we were afraid nobody would stick around for our talk. On the contrary, we had a room full of engaged attendees. As we entertained questions from the audience, one attendee stood up from the front row and said nothing, but just began clapping. She turned to the audience and continued to clap, offering up her own personal standing ovation. I was thinking to myself wow, this attendee is quite enthusiastic. Not to mention she has some guts to stand and do that. She then turned to us and said “Ladies, you NAILED it.”

 

Then she identified herself. It was Mary Massery.

 

For those of you who aren’t PTs—this would be akin to having Coach K stand up and applaud you as you gave a talk to the entire NCAA on new and innovative approaches to coaching men’s college basketball. Yes, of course I’m going to use a Duke basketball reference after that win over UNC this week.

We were starstruck, to say the least. For Blair and I, both of our jaws immediately hit the floor. According to Blair, this was like being thanked at the Oscars. Julie W knew her previously but it was clear that was very meaningful to her as well. When I was in PT school, I was told by multiple professors that if you ever had the opportunity to learn from Mary Massery-you do it without hesitation.

To add vulnerability to humility—I had even quoted her twice within the presentation, not knowing she was sitting on the front row. This, ladies and gentlemen, is exactly why we are always taught to check and double check references before quoting someone! My 5th grade and high school journalism teachers would be so proud.

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Giving credit where it is due!

Mary happened to escape the room before I had a chance to thank her and shake her hand. Good news is she’s coming to Atlanta later this year and I will get to do that AND learn from her, as recommended to me when I was a novice PT. She did send an email to us later commending us on our effort. It’s not quite a hand shake, but my jaw may or may not have hit the floor again.

Overall, it was a wonderful experience. Among my many reflections, here are a few pearls I picked up along the entire journey:

  1. Like in any sport or activity-you can prepare, rehearse, perfect, and polish to the nth degree-and things will still go wrong. The key? Learning to roll with it and breathe through it. You’ve got this.
  2. Humility, vulnerability, and grace go a long way. It’s not about YOU in sharing your message. It’s about the people with whom you share it. It’s more important to establish a connection with them in order to get the message across than to worry over the details of the actual message. People only retain 10-20% of what you say. So it’s not about what you say-it’s why and how you say it. Be yourself, add some humor and fun—and people will really engage with you. This makes it a lot more fun as the presenter, too.
  3. I say this all the time—but teaching is not a teaching experience. It is a learning experience for the teacher.
  4. Blogging is a fantastic platform for sharing passions and messages. It’s even more fun when you are given an actual voice on an actual platform, and you get to wear heels to do it. Thank you Blair for letting me raid your shoe closet.
  5. The unconditional support, compassion, and reinforcement I received from people who barely knew me was so humbling and validating. It has been amazing to receive messages and emails from people who just want to network and share their stories with me. What an incredible profession to be a part of.
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Duke alums in PT gathering! Some of my favorite PTs in the world in this photo!

I’m thankful for the opportunity to have shared my stories and passions with so many people. I can only hope that even just one person has been able to integrate some of those concepts into their daily practice.  I gained new inspiration not only for this blog, but reinforced and reinvigorated my curiosity and passion for so many things related to the care of young athletes. As I come down from the CSM high-or hangover as I’ve called it-there is plenty to integrate into my practice. Lots of new connections, friends, and knowledge. I haven’t even started to reflect on all the cool things I learned at the conference in all the classes I took (another post for another day). Stay tuned!

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Emory DPT Classmates. Love these guys!

 

Swimmer’s Shoulder: Best Friends and Mortal Enemies

Athletes of all ages and backgrounds thrive on efficient movement, maximizing results with as little energy as possible. In swimming, inefficiency can lead to many injuries, especially shoulder pain. Meet a swimmer’s best friends and mortal enemies. It’s often the enemies—those that pretend they’re friends—who cause the most trouble. ­­

BEST FRIENDS

KISS Principle and the 3 Bs

When it comes to swimming efficiency, we need to establish two simple truths for keeping it simple, swimmer (KISS):

Truth 1: Swimming is not all about the arms. You may have lats (“swimmer muscles”) of steel, but they do more than propel the body in water. They interconnect with the core and are sewn into your glutes. The arm bone is connected to the leg bone after all! But that doesn’t mean it has to do all of the work. Truth 2: Swimming is all about the 3 Bs: balance, buoyancy and breathing. But how do you make those your best friends? Read on to find out how to use them to help your arms and swimming efficiency, specifically in the freestyle (front crawl) stroke.

Be strong and carry a big kick

“I am not a strong kicker” and “I hate kick sets“ are common quotes from swimmers with shoulder pain. We may love-to-hate kicking, so let’s make it more digestible with a metaphor. Imagine you have a beautiful boat that you use each week. You’re thrilled until one day—BAM! The boat starts to slow down and feel sluggish each time you take it out. You take impeccable care of your boat, so you’re baffled. You take the boat to a mechanic, who asks how you drive it. You proudly present two paddles that you hand-carved. He smiles and points at the boat’s motor. “This is a motor boat,” he says. “Have you been paddling it all along?” You answer, “Yes! I don’t want to pay for gas and put in the time to service the engine!”

Friends don’t let friends overlook the importance of having a strong motor in the water. Using your “paddles” to do all of the work is not only inefficient, but it will slow you down and worse—potentially injure you. Dragging your motor along is added weight for your arms to pull. Use that weight to your advantage! Find a precisely balanced use of that motor coupled with good body rotation (twist), balance, and buoyancy so that you won’t have sore “paddles.” Want to know more? See this article about efficient freestyle kick in swimmers and triathletes.

Do the twist

There is no one-size-fits-all answer to swim posture and balance, but here are a few guiding principles:

  • Head position: Head position and shoulder pain are related. Poor head posture begets a sluggish hip position and vice versa, leading to a sluggish motor. Gaze through the top of your goggles instead of tilting your head up. Keep the water line at mid-forehead or cap line.
  • Pelvis and hip motion and rotation: drives the kick, which in turn drives the body, then the arms. This requires glute and hamstring strength and flexible hips.
  • Upper back: follows the pelvic and motor motion. You need flexibility and strength into twisting motions in the upper/mid back, shoulder blades, abs, and low back.
  • Knees and ankles: neither held too rigid nor floppy. Kick from the hip, not the knees or ankles.

Utilize your own personal floatation devices

If you don’t breathe well, your motor and 3 Bs will suffer. Swim lessons begin with bubble blowing and floating for a reason: to teach use of the most buoyant part of the body—the lungs—to stay afloat. Diaphragmatic breathing keeps your core engaged with your arms and delivers oxygen to your muscles. And be an equal opportunity breather! Breathe bilaterally to keep the work balanced on each arm/leg.

Swim toys: the good guys

  • Swimmer’s snorkel: Ditch the nose plug. The swimmer’s snorkel may help you with the 3 Bs. It keeps your head and body in line while working on your body rotation and kick. Sure, you won’t breathe to both sides or compete with it, but it does help you sync your inhales and exhales with your strokes. That’s a step toward 3 B success and a best friend for swimming life!

    Photo credit: swimswam.com

    Photo credit: swimswam.com

  • Swim fins: Not only will they help you practice your Little Mermaid impression, but swim fins will also help you run over everyone at practice. While they are no replacement for establishing an efficient motor and 3 Bs on your own, they do boost kicking and, in exchange, take a load off of your arms. Word of caution: if your ankles are stiff, they can cause shin pain.

Hand entry

It’s easy to get caught up on hand entry (pun intended). It’s important, but not everything. Hand entry is akin to a runner’s foot strike: both are dependent on body position. This has less to do with your arms and more to do with—you guessed it—kicking and the 3 Bs. With these in check, the hand should enter fingertips first, just wider than the shoulder. Too wide or too narrow likely means there’s under- or over-rotation in the hips and torso, respectively. This can lead to technique issues and stress the shoulder.

Training terrain

This is mainly applicable for triathletes and open water swimmers, though pool swimmers can benefit from this part, too. Just as trail runners need to train off road and road cyclists need to train on the road, swimmers need to train in their competition “terrain.” Accessibility, weather and water temperature pose a challenge here. For open water races, train where you can’t see in front of you. Vision affects the 3 Bs, so practice lifting your head too look for race buoys, support crew, and other competitors. Just remember keeping your head up too long will affect your 3 Bs and motor. If a current or waves are involved, train in choppy water. Wear your wetsuit before race day to ensure fit, comfort, and no change in your 3 Bs.

MORTAL ENEMIES

Improper FITT

That’s not a spelling error, and I’m not referring to swimsuit fit. That’s training Frequency, Intensity, Type, and Time. Too much or too little of each can be problematic. Periodic muscle soreness is normal, but should taper with experience and improved technique. Increase training distance or duration by no more than 10-20 percent per week and vary your strokes to allow for this gradual change. Having stroke variety (e.g. breastroke or backstroke) in the back of your Speedo can be handy if you need to change your position or speed in a race.

Swim toys: the bad guys

  • Kick boards: Kicking is essential to healthy shoulders, but kicking with that 12-inch piece of foam is not. It puts the shoulder in the “impingement” position, pinching your rotator cuff and other structures against your scapula. That’s PT-speak for “ouch.” Kicking with no board helps master the 3 Bs. Kick on your side with one arm up or on your back or stomach with both arms down.
  • Hand Paddles: These are a privilege, not a right. Added resistance is great for building shoulder strength and to the swimmer who paddles the motorboat. Remember what I said about the arms? It’s not about them! Unless you have no pain, a good kick and the 3 Bs, just don’t even go there.
  • Pull buoys: Why would you take away your motor especially when your shoulder hurts?

Poor ergonomics in other activities

What you do out of the pool is just as important as in the pool. Poor cycling and running posture can beat up a shoulder. That goes for workplace, school, and car ergonomics, too. Habits accumulate quickly and can catch up to you when you least expect them.

IN SUMMARY:


Now that you’re armed with a checklist, you’re ready to dive in and make lots of new best friends. But if you find you’re having trouble with them, don’t wait until you’re in pain to ask for help. Sports physical therapy is not just for when you’re broken. We can identify factors that may put you at risk for injury not only in swimming, but in other activities too. Video stroke analysis can be key to help identify and correct errors that may strain a shoulder.

Pilates: Not Just for Grown-Ups

“Hey, do you know of any places where my daughter can do Pilates after she is finished with PT?”

“Should my 6 year old do Pilates classes?”

“She has a stress fracture in her back and the doctor said she needs to strengthen her core. I heard Pilates is good for that so I bought her a DVD. Is that ok?”

“I need to do Pilates as conditioning for dance. What should I do?”

I get these questions all the time from parents and young patients. My answer to them has often been “Well it depends.” That is, until recently!

One month ago I had the absolute joy of attending the Pilates Method Alliance® Pilates 4 Youth teacher training in Berkeley, California. What a fabulous 2-day course in the most beautiful setting with the most interesting and brilliantly creative minds!!! It was perhaps one of the most inspiring courses I have taken in my entire PT and Pilates career thus far. It helped that we had a nice view of the San Francisco Bay, San Francisco, the fog, and the Golden Gate Bridge the whole time. I called it my #nerdcation.

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Claremont Hotel & Spa in Berkeley.

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I’m not sure if I spent more time learning or more time gazing out the window from my seat

The course was full of 60 or so instructors from all over the USA and the world who work with children and adolescents in all different settings: schools, clubs and camps, inner city wellness initiatives, health care/PT clinics and private practices, girl scout troops, and private Pilates studios.

The course was led by Celeste Zopich, Brett Howard, and Dawn-Marie Ickes, who co-authored the course manual and textbook Pilates for Children and Adolescents. These three brilliantly creative master teachers spearheaded the Pilates in the Schools movement, an initiative begun in the early 2000’s in the wake of decreased physical education time in public and private schools. You can read more about Pilates in the Schools and the research project they did with the kids here.

Watch a video about Pilates 4 Youth & Pilates in the Schools here:

I can’t say enough good things about the instructors. Celeste has a wealth of experience teaching in a parochial school. Brett teaches classes for children of all ages and brought a wealth of research and creative cueing and activity design perspective to the group. Dawn-Marie, the PT & Pilates teacher of the book, seems to be leading a life rather parallel to mine on the west coast. She works not only with young clients and incorporates Pilates into PT with them, but also has a special interest in women’s health and is a Redcord Neurac teacher trainer. I can’t wait to continue following these three as the Pilates 4 Youth initiative continues to take off.

See interviews from the book’s authors & course instructors here:

Too often children (especially girls) drop out of sports by age 13 due to burn out from early specialization, self esteem and body image issues, lack of success and fear of failure, or lack of funding from parents or other guardians. Or—on the other hand, children do not become active in the first place for so many cultural and societal reasons (that I don’t have time to discuss in this blog post) and we have even bigger problems of childhood obesity, low self esteem and body awareness, and low exercise interest or confidence.

Perhaps most interestingly, the course taught us about the “magic window” age of 9-13. This is when kids and teens are at the most vulnerable for both physical and psychological injury. The mind-body approach of Pilates targets these problems in a very kid & teen-friendly way. This is the best stage to intervene from an injury prevention standpoint in PT, too.

Favorite video quote from videos above (from a 13ish year old):

“Well I’m a swimmer and doing regular Pilates has helped me a lot with having regular breathing and opening up my shoulders and using my back muscles to move my arms.”

If that quote doesn’t sum up my personal and professional vision for helping my most beloved target clientele, I don’t know what does.

In the course, we learned how to design classes or private sessions for children of all ages and ability levels, from 5-6 year old girl scouts to 18 year old elite Olympians,. We had a great segment taught by Dawn-Marie on program design for children with special needs, or “special opportunities” as she liked to call it. She reminded us that all children and teens have challenges that vary on a long, diverse scale, regardless of the diagnosis or “category” in which they are placed. For youth of all ages and ability levels, it is our duty to determine how best to tap into each of their movement systems, regardless of the challenges and opportunities they face each day.

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Superhero themed Pilates! It’s not hard work when you’re having fun while learning! I bet I know a few adults who would probably want to come to a class like this one…

 

 

 

 

 

 

 

 

 

 

The Pilates 4 Youth initiative is in a pretty grassroots stage now. So far the course has been put on twice to a total of about 150 people thanks to a grant from a generous donor. Hopefully it will continue to grow in popularity so that we can improve access for children of all ages to Pilates in a non-competitive environment. But we’re not exclusive to Pilates. And we are all over social media!

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#hashtags are everywhere Follow the PMA on twitter at @PMATWEETER

Stay tuned! I’ve already been incorporating Pilates into my clinical practice for several years, but I’m anxious to start incorporating many of the new concepts I learned into practice and hopefully into group classes in the community soon. I’m excited to exercise my creative juices and have already invested in some fun tools to help me do so:

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That’s a scooter board

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Fabulous imagery and kid-friendly Pilates terms

To learn more about the Pilates 4 Youth initiative, check out the information on facebook.

“First, educate the child.”

Joseph Pilates

Movement is medicine for low back pain

 

Just ran across this great whiteboard video from an NPR post about low back pain. It’s a video by a Canadian primary care physician. It’s the best patient-friendly explanation I’ve seen of low back pain, what to know, and what to do about it.

While low back pain in the young athlete is not always the same as in adults and there are other kid- and teen-specific diagnoses AND PT treatments to consider, I still find this video very helpful for all ages. Though there are some very rare reasons they may have it, kids and teens almost never have problems like neurogenic claudication due to spinal column narrowing mentioned in the video. Discogenic pain is also more rare in kids and teens..

Given that low back pain is one of my favorite conditions to treat, particularly in the young athlete, I’d say this video hit the nail on the head for the most part. I love the physiotherapy, manual therapy, and Pilates shout-outs in the video.  It’s important before beginning something like Pilates or yoga that you start slowly and ensure that your instructor is familiar with how to help people with injuries. In addition, if you are a kid or a teen, it’s important that the instructor is skilled in working with children and adolescents as there are special precautions that must be made in Pilates and yoga due to differences present in the growing spine vs. the adult spine. Typically what I do, as a Pilates instructor and PT, is teach kids the right movements they would need to know for Pilates, then find them the right Pilates instructor or class.

You can skip the ad at the beginning, but I also love the Neurac and WebPT advertisements at the start of the video. Between Pilates, Neurac, and WebPT, I use all of these things in my daily practice (in full disclosure: nobody paid me to say that).

The best 3 lines:

“Motion is lotion”

“A physiotherapist can probably help you with all of these things” 

“Movement is medicine.”

Enjoy!