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Now displaying: February, 2021
527: Dr. Alli Gokeler: Motor Learning & ACL Rehab: Do We Need It? 0
In this episode, sports physical therapist specialist, Dr. Alli Gokeler, talks about motor learning.
Today, Alli tells us about the process of motor learning, how patient autonomy is advantageous to rehabilitation, and how to motivate patients. How does Alli measure motor learning outcomes? Alli elaborates on his on-field rehabilitation model, and the importance of incorporating cognition in ACL injury rehabilitation.
Alli talks about RTS from a motor learning perspective, how to continue motor learning on the field, and he gives his younger self some advice, all on today's episode of The Healthy, Wealthy & Smart Podcast.
Alli defines motor learning:
"In order to acquire motor learning, you need to practice. If you don't practice, you can't learn something."
"The learning process itself cannot be measured directly. It's only something you can measure indirectly."
"What motor learning should result in is: it should lead to relatively permanent improvement of motor skills."
"Be careful how you interpret this process. Quite a few clinicians have a tendency to provide feedback because they intuitively try to correct a patient."
"Be a little bit patient with your patient, because learning takes time. Don't interrupt the learning process too soon."
"Motor learning, as well as learning a language or math, is a non-linear process."
"One of the strong drivers of learning is intrinsic motivation."
"We provide our patients with a significant amount of autonomy, which means the patient gets a certain level of control over the exercises."
"Providing autonomy during rehab enhances learning."
"Around 70% of people prefer to receive feedback after a good performance of an exercise. What happens in most clinical situations, with all good intentions, we typically give corrective feedback, which typically means you didn't do something according to the standards of the therapist. This may affect their motivation."
"If you look at the brain activity of someone that is instructed to do something, or the brain activity of a person who has some control over what they're going to do, you have completely different brain patterns. When you give them some control, they are much more engaged, and this is a prerequisite in order to learn something."
"If you want to be certain that learning has taken place, you need to measure, otherwise you can't be sure that the patient has learnt something."
"If you're good at something, it's not challenging anymore. If it's too difficult, then it's overreaching."
"One-on-one training is not what's needed for a football player. They are team athletes."
Alli's on-field rehabilitation model:
Neurocognition: Reaction time, decision-making, selective attention, inhibition and working memory.
Motor component: Strength, range of motion endurance, and speed.
Sensory: Visual, auditory, and environmental factors.
"We need cognition during our motor control, and if we only work on pre-planned activities, we miss something from the on-field situation."
"An ACL injury isn't just a peripheral injury, but it's also a neurophysiological lesion, and that needs to be considered in rehab."
"With colleagues that work with paediatric patients, some of the motor learning principles that they use could be very beneficial for us working with orthopaedic, sports-related injuries."
Motor Learning, RTS, PDCA, ACL, Rehabilitation, Neurocognition, Therapy, Physiotherapy, PT, Training, Injuries, Sport, Wellness, Health, Recovery, Injury-Prevention,
More about Dr. Gokeler
Dr. Alli Gokeler has 28 years of experience as a sports physical therapist specialist.
In 1990, Alli graduated with a degree in Physical Therapy from the Rijkshogeschool Groningen. Following his graduation, he worked in both the US and Germany as a physical therapist. In 2003, he earned his Sports Physical Therapy Degree from the Utrecht University of Applied Science. In 2005, he started a PhD project at the University Medical Center Groningen, Center for Rehabilitation.
He is a researcher-clinician and a clinician-researcher with a passion for multidisciplinary injury prevention. He has over 40 peer-reviewed publications, and he regularly gives lectures worldwide. In his free time, he loves to do mountain biking.
To learn more, follow Alli at:
Facebook: Motor Learning Institute
Instagram: @motorlearninginstitute
Twitter: @Motor_Learning
YouTube: Motor Learning Institute
Website: https://www.motorlearninginstitute.com
ResearchGate: https://www.researchgate.net/profile/Alli_Gokeler
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Read the Full Transcript Here:
Speaker 1 (00:07):
Welcome to the healthy, wealthy, and smart podcast. Each week we interview the best and brightest in physical therapy, wellness, and entrepreneurship. We give you cutting edge information. You need to live your best life. Healthy, wealthy, and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now here's your host, Dr. Karen Litzy. Hey everybody.
Welcome back to the podcast. I am your host, Karen Litzy and today's episode is brought to you by net health. So net health is hosting a three-part mini webinars series on Tuesday, March 9th, entitled from purpose to profits. How to elevate your practice in an uncertain economy after 2020. I think you're going to want to sign up for this. So you're going to hear from a panel of guests that have over 50 years of combined experience working in the PT industry sign up will begin tomorrow, which is Tuesday the 23rd, February 23rd for this mini webinars series. So head over to net health.com/litzy to sign up once again, that's net health.com forward slash L I T Z Y. So check it out and sign up now. Oh, and it's free. Okay. So this whole month we've been talking about ACL injury and rehab. So today's episode is with Dr. [inaudible].
He has 28 years of experience as a sports physical therapist specialist. In 1990, he graduated with a degree in physical therapy from I'm not even going to pretend to try and pronounce this. So you can just go onto the podcast website to find out where he went to school. Cause I'm not even going to attempt it following his graduation. He worked in both the us and Germany as a physical therapist in 2003 here in does sports physical therapy degree from you trick university of applied science in 2005, he started a PhD project at the university university medical center, grown again, center for rehabilitation. He is a researcher, clinician, and a clinician researcher with a passion for multidisciplinary injury prevention. He has over 40 peer reviewed publications and he regularly gives lectures worldwide in his free time. He loves to mountain bike and you can check out more from him and his research@motorlearninginstitute.com.
Okay. So today we talk about just that we talk about motor learning. So the process of motor learning, how patient autonomy is advantageous to rehab, how to motivate, how to measure low motor learning outcomes on field rehab models and the importance of cognition and ACL rehab. And we talk about Allie's brand new model for Mona motor learning, which will be out hopefully in a month or so. So a big thanks to Allie. And of course, thank you all for listening to this month on ACL injury and rehab. Hey, Alli, welcome back to the podcast. I am happy to have you on once again.
Thank you for inviting me. Yeah. It's been awhile pleasure to be here today.
Yes. And so, as people, if you've been listening to the podcast, you know, that this month has been all about ACL injury and rehab. And so what better person to have on the new to talk about kind of the rehab process after an ACL injury and your specialty, which sort of motor motor learning. So the first thing I want to ask you is can you define motor learning?
Yeah, that's it, that's a very good question. And I I've taken three, I think important aspects of motor learning that I think are relevant for clinicians that listen to this podcast. The first one is in order to acquire motor learning, you need to practice. If you don't practice, you can't learn something and that may be pretty straight forward, but I still think it's important. The second one, and that's a little bit of a vague one, but the learning process itself cannot be measured directly. It's only been some been something that you can measure indirectly. And I I'll touch back on that a little bit later. What I mean by that? And the third point is what model learning should result in is that it should lead to relatively permanent improvement of motor skills. And last year I gave the example of writing how to ride a bicycle for this year.
I thought, Hey, maybe skiing is a good example. And so if you've taking ski lessons as a teenager and you became quite proficient in skiing, it could be for many different reasons for job or any other reason that you haven't been going to the Rocky mountains, but at the age of, let's say 35, you have some time again, and you have some financial resources and you'd, Hey, let's spend the week again in Vermont or the Rockies and maybe a little bit of rusty at the beginning, but perhaps after a day or two, you get the hang of it again. So this is I think a great example of what motor learning means. It means that you acquire something and it sustains over time. Now that needs to be distinguished from performance. And this is, I think one of my key messages that I would like to point out to clinicians when you work with your patient in the clinic and you have your patient doing an exercise.
And this relates to my second point is that motor learning is not directly observable. What you see in the here and now is performance. Now I get, I can give you two examples. So let's say you have a patient after an ACL injury six weeks post-op and you want to have your patient work on balance, not patient number one comes in and stands on one leg. And actually what you're seeing, you're very happy, very stable not any excessive movements is able to maintain balance for 30 seconds. Okay. You're you might be happy with that. Now, your second patient comes in from the same surgeon, also six weeks post-op and when you have this patient perform the same exercise, you see that a patient sometimes needs to take the hands of the hips or needs to hold onto something, or puts the other foot down to maintain balance.
And from these two examples, you may draw the conclusion that the first patient has better motor skills and has better learning potential. And the second one has poor motor skills and is not such demonstrating good learning potential. We don't know. We only, we only know that performance in patient one is better for sure. Performance in patient B is not as good for sure, but that doesn't mean that the dis says anything about the learning potential. In fact, it may be that the learning potential in patient one is, or has already been reached because this is at the max of his abilities, various for the second patient with poor performance, there may be a large learning potential. So that that's that's I think very important. And what you need to consider as a clinician is be careful how you interpret this process, because what I know from my early days, and also when I teach courses, is that quite a few clinicians have a tendency to provide feedback because they would intuitive to literally try to correct patient too, because you see that it's not able to maintain balance.
So we need to say something. So we will usually do that in with feedback. And we typically do this with corrective feedback. And my second take home message would be, be a little bit patient with your patient because learning takes time. So maybe unless you feel that there is an unsafe situation, but if that's not the case, let the patient practice and re evaluate in the week or in two weeks time. But don't interrupt the learning process too soon. Because when I go back to the skiing example, remember when you haven't been skiing for for like 15 years or when you started to ski, it, it, it was probably something like this first day, quite difficult. Second day, still difficult. You might even get frustrated third day, no improvement. However, on the fourth day snow not being able to ski ski lift is closed.
And on the fifth day means there was no one day without any skiing lessons on the fifth. There you go out again, Hey, and all of a sudden you feel like, Hey, I I'm, I'm better than I was on day three, although you haven't practiced in the day in between. So this is what I mean, learning is not only happening as you practice, but there's also some processing afterwards going on in your brain that helps to acquire those motor skills now. And if you interrupt that process like vote by providing a lot of corrective feedback you may actually, although with all good intentions, I don't want to disqualify that, but maybe it's better to leave the process happening and evolve and then provide feedback later on.
Yeah. It kind of reminds me of have you ever heard the term helicopter parent? So it's the parent that's always hovering over the child, making the decisions, not allowing them any autonomy for themselves. And so it reminds me of that helicopter therapist who's on top like, Oh, I see that if you use the example of balance, Oh, I see that you struggled a lot with your balance. Why don't you try and do this? Well, why don't you do this, try this, try this, try this. And, and in that as the therapist, are you taking away the autonomy for the patient and what kind of, how can that affect the outcomes for that patient?
Yeah, that's an excellent point. Karen C motor learning, as well as learning a language or learning math is a nonlinear process, which means how you learn how to ride a bicycle was probably different from how I learned it. So, but what we typically do as clinicians, we have this, this, this clinical guidebook in our, in our mind map that we think based on our experience or based on our beliefs, how we need to guide our patients from simple skills to more advanced skills from single task skills to do a test skill, whatever. However, we don't know how this patient is actively engaged in this process, actually, by example, that you were provided the, the patient is directed by the, by the parent or, or the child is directed by the parent and is actually a passenger. Now, I think one of the strong drivers of learning is intrinsic motivation.
So what role do you give your patient if you direct them, where to go, what to do, and also you give them corrective feedback are these all strong drivers for self-organized learning? I'm putting a question Mark behind it. So people need to think about them for themselves. I can tell you what we do in, in, in our clinical situation. And that's based also on our research we provide our patients or in ACL injury prevention, we provide a significant amount of autonomy, which means an athlete or a patient gets a certain level, not complete control, but a certain level of control over the exercises. So they can choose, for example, out of 10 exercises, they can pick three exercises that they would like to do on that particular day, in an order they would like to do. And we know from a substantial body of research that providing autonomy during during rehab enhances enhances learning.
And I can tell you this from a research point, but it can also give you a brief insight from a recent survey that we've done among patients that completed their rehab. And we sent them an open questionnaire about their experience in in the entire process of rehabilitation. And one thing that two things that really stood out were a positive environment, a positive environment with relatedness of the therapist towards the patient, and not as a patient, but as a person that's quite important. So it's not a ne it's not an ACL patient. No, it's, it's, it's a person with an ACL injury. That's quite, quite, quite an important distinction. And the second thing that stood out was and you, you touched on that before is the autonomy some self-control over the rehabilitation process. And this was a qualitative study that we did my PhD student while surveilling ran the study.
So it's not something that I'm just saying as a scientist, but this is also what we get back from our patients. And when we ask them so going back to the clinical situation this is what we apply also by providing our patient with the opportunity, instead of me always providing the feedback I'm asking them, or I'm giving them the opportunity please let me know when you want me to give you feedback. That is a great example of of autonomy, the thing, easy question. Yeah. And, and, you know, what's, what's, what's what's quite important to understand is if w if we think how humans preferably like to receive feedback if we, if we, if we ask a healthy population and the same applies to to an injured population, it turns out that around 70% of the power of the people prefer to receive feedback after a good performance of an exercise, what happens in most clinical situations with all good intentions? I really don't want to question that, but we typically give corrective feedback, which typically means you didn't do something according to the standards of the therapist. That means that maybe seven out of the 10 people that you provide feedback to may not really like this, and this may affect their motivation. This may affect their learning potential because they like to receive feedback when something went well, they, they conversely they already know when something didn't go well and they don't need us to rub it in or to remind them they already know.
So you, you touched on a word that I was just going to ask you about, and that is motivation. So why is motivation key in motor learning?
If you look for example, at the brain activity of a person that is instructed to do something, or you look at the brain activity of a person who has some control over what they're going to do, you have completely different brain patterns. And I can tell you that the second one, the second example, when you give them some, and when they can choose, they are much more engaged, and this is a prerequisite in order to learn something.
Yeah. And, and I think we can probably all look back on our own personal experiences of learning, whether that be academic learning, or learning a physical task. I think we all like to have a little bit of control over that versus just have stuff thrown at us without our IM without our input or without our thoughts on it. So I think that makes perfect sense. And now, so we spoke about how motor learning is, non-linear why motivation and autonomy is so important. Now let's talk about, we've got this patient with who had an ACL repair and they want to get back to sport. They, they are, they are ready mentally. So we'll put that to one side. They're ready mentally. So let's talk about the return to sport from a motor learning perspective.
In my opinion, return to sports is we first need to define what we mean. And I think the 2016 consensus meeting gave us some leeway in that direction. And I think one of the most important things that stood out is that it's a continuum. It is not one moment in time. And I think what I read in the literature often is is that it's such a that coma to choice yes or no at at six months or nine months, whatever you're, you're, you're, you're believing in. I think what we need to understand is certainly in light of the high number of secondary ACL injuries, particularly in the young population, in, in, in pivoting type sports, that's number one. But also the second one is that, you know, only, I think a disappointed percentage of people reach their pre-injury level.
So their performance is not up to par. So do those two factors. When we, when we look at that, I think it all starts prior to the surgery. So the rehabilitation, I think is one of the key factors that we need to, that we need to consider anything that's left. Unaddressed will show up even in higher magnitude, after the ACL reconstruction, which was the second trauma to the knee. And, and then in, during the entire rehabilitation process, something very simple. And I can't stress that enough if, if walking is not normal and how do, how do many clinicians assess a normal gait pattern? They usually ballpark it, but, you know, even a slight deficit of five degrees is clinically meaningful. And now, now just follow some logical sense. If you're walking is not normal, what do you think will happen with the running?
W what do you think, what would you expect? How, how the squat will be executed by the patient and how will the single leg up will be done or a drop foot, a good jump. So that's why I think that all these elements from a motor learning perspective, and also we'll touch back on that a little bit later, of course, sound strengthening program, you know, no question about it, very important, but I think it is, it is very important to also incorporate the model learning process so that we make sure that the patient is learning or relearning those motor skills, but Mo and I can also stress enough. It's also important that we as clinicians really, really measure and boarding and, and I, we just completed and published a study among Flemish physiotherapist. And one of the things that came out of this study is that many don't use the evidence-based principles, meaning also they don't use two criteria as they don't assess and in order, and that's also coming down to model learning. If you want to a certain that learning has taken place, you need to measure, otherwise you can't, you can't be sure that the patient has learned something.
And how do you, what are some examples that you can maybe give the listeners of how you measure these motor learning outcomes? Because I think that's important to let people kind of wrap their heads around that. And on that note, we're going to take a quick break to hear from our sponsor and be right back
On Tuesday, March 9th, net health is putting on a three-part mini webinars series entitled from purpose to profits, how to elevate your practice in an uncertain economy after 2020, you're going to want to sign up for this. You're going to hear from a panel of experts that have over 50 years of combined experience working in the PT industry, signup will begin tomorrow for this mini webinars series. So head over to net health.com/litzy to sign up once again, that's net health.com forward slash L I T Z Y.
Yeah. So I use, then that's something from, from the business that you probably know that the PDCA cycle, the plan do check act and the P and the plan, which means you do a baseline test. So first you need to let's say balance. So there's the patient have a balance deficit yes or no. You can use the star balance says you can use th the balance error scoring system. That's your baseline test. Now, it's up for you as, as a physiotherapist with your clinical reasoning. Does the patient need an intervention to target a balance? Yes or no, or are we happy with, but let's assume now there is a balance deficit. Now we go to the do, which means what is my intervention? So my intervention could be, I'm planning to do balance training for four weeks, with two therapy sessions in the clinic, and four sessions at home consisting of those and those exercises.
And then AF in between I'm doing an interim evaluation, is the patient going on track as I'm expecting or not? I can still find tune my my intervention program, a training program. And then I do a final assessment after, after two weeks and preferably even one little bit later on as well to make sure that the effects of the balanced training are really sustained over time. Remember what I said about riding a bike or skiing and that's a very simple procedure you can use. It doesn't take a lot of time but it's, it needs to be integrated in your daily practice because if you don't measure, you don't know.
Yeah, absolutely. And I love that. I think people can get behind that PDCA cycle and cause, you know, PTs love things that are regimented and you know, things that sort of follow a plan. So I think this is a really easy, and I think people can get behind it. And I also think that it will keep your patient on track and keep you on track and organized versus just like throwing whatever up against the wall and seeing what sticks, if you measure it, you're, you know, you're, you kinda know where this patient is going and that makes all the difference.
Yeah. Which, which th that's a good point that you I, I forgot to mention it actually in the, in the, in the planning cycle, I'm incorporating my patient. So I'm discussing the baseline tests and I'm asking in my patients, so you have a balanced deficit. What do you think is needed for you to improve your score? What do you think is could be if you score eight out of 10, so zero would be no balanced error. 10 would be the maximum errors that you can acquire. So you have an eight, what do you think is reasonable to achieve in two weeks time, for example, and then the patient could say, yeah, I think I'm I can reach a seven. Hey, that's the interesting information. Why, why are you so conservative? Why can't, why can't you challenge yourself from, from an eight to a four, for example?
So I always creating this interaction with my patient. You know, I can in conjunction with, with, with me and my patient, I can set goals that, and that's quite important as well. That need to be challenging for the patient, because if you, if you already a good or something, you're not challenging and it's not challenging anymore, if it's too difficult, then you then it's overreaching. But it, it has to be something that the patient sees. Okay. I really got to put some effort into this is again, which is, again, something for important for learning.
I was just going to say that I said from a motor learning standpoint, if you do nothing that gives a substantial challenge to your patient, are they really going to see the benefits of those exercise or of your plan? Exactly. Yeah, yeah. Yeah. That makes perfect sense. Okay.
And also going back to to the first example where the two patients with the balance exercise, if, if I give my patient an exercise, it is usually an exercise that creates difficulty for them. So if I see a perfect demonstration, then I'm kind of thinking, yeah, what is the learning potential here? So I purposely make the exercise a little bit more difficult right away. And I explained that to them, I'm explaining to them, don't expect to, to master this exercise today or tomorrow. And I always give that example of, of riding a bike and, and a lot of patients like that because, Oh yeah, I remember that I fell down quite a few times and and that that's in ACL rehab. It's, it's more or less the same process.
Yeah. And, and I also want to switch, well, this isn't really switching gears just moving forward. So yes, we know that return to sport is a continuum you've got returned to sport and returned to performance, different things. And one of the things that I spoke about with Nicole [inaudible] is the importance of on-field rehab. So I know that's something that you're also passionate about. So do you want to kind of tie that into what, what therapists can do on field to continue to foster this motor learning within their sport, whatever that sport may be?
Yeah. I think that's, that's something that's underappreciated and, and maybe that's because we haven't really integrated the motor learning processes in our rehab. And one of the things that we have to consider is when you observe your patient in the clinic and you a certain motor behavior, that's all what it means. It stems down to the interaction between the environment. The task at hand could be a jumping exercise, could be a single lag, actually, whatever. And, and, and, and to behavior that you're seeing. So there is a task athlete, environmental interaction, which means the movement that you see from that interaction only is valid for that interaction. You cannot extrapolate a jump landing strategy from a box in a physiotherapy clinic. And imagine how this athlete would play lacrosse or American football or soccer. It's completely different game, completely different worlds.
So I think that's where one of the main reasons why single leg hop test and accessed by, by, by Kate Webster and, and, and Tim, you, it were shown not to be valid predictors of secondary ACL injury, because a hop test is something completely different than how an athlete performs on the field. So, in, in, in that regards I think we need to take the patient to the field and to see how the patient is performing based on that interaction that I just refer to the tasks, the environment, and the athlete interaction. And then you get meaningful information where the, where that patient is is add, which for example also means that one-on-one training is not what's needed for a football player. They are team ball athletes. So you need to do something with the ball. You need to be on the turf and you need to do something with teammates
That yes, when you're working with someone with a team sport, you have to have those other I don't want to say distractions, but you know, other people, a ball scanning a field versus just going one to one with you.
Yeah. And we, we've just completed an analysis of 47 non-contact ACL injuries in Italian professional football. Just this work that I've done with Francisco Della Villa from the ISO kinetic group. And what we did is we, we looked at the injury mechanism through a different lens and what we the lens we use was a neurocognition lens. So we looked at the inciting events that happened before the ACL injury took place, because so far the literature is predominated by the dynamic valgus collapse. And I totally agree. I totally agree. However, it doesn't tell you what led to the injury. It just tells you what the end point is. That's dynamic velvets now. And what we've done now is what are now some typical events occurring during a match play in which a non-contact ACL injuries took place. And we took two neurocognitive factors. One is the selective attention. So are you able to maintain attention to the relevant information in this regard and filter out irrelevant information? And the other one is, did we see some impulsive behavior of defenders? And they were running into a situation in which basically the attacker waiting for them to approach. And then at the last moment, they made a deceiving action that the defender did not entail.
And now in the very small timeframe,
The defender had to change the movements in a timeframe that you don't have enough time to coordinate those movements well. So if you think about this as a framework, how injuries may happen, we also need to consider this framework, how we integrate that in our rehabilitation process. And this is what I do from day one. And certainly this is what I do re related back to your question for the on-field this framework we use for the on-field rehabilitation. And I've created a model for that.
Yeah. So I was just going to say, I know that you've created a model and it's going to be published soon. So let's talk about what that model is. And if you can kind of walk us through that, that would be great.
So the model is consists of three main pillars. The first one is neurocognition and neurocognition, you need to think about reaction time. Decision-Making selective attention, as I mentioned before, but also your ability to control impulsive behavior. That's called inhibition. Can you, can you change your intended movement? Yeah. That's something to control your impulses. Very important. Working memory is another aspect. So those are the neurocognitive components. Then we have the motor component, and I think that's where most physios will be quite familiar with. So we think about strength, range of motion endurance speed, things like that. Yeah. That that's, that's I think pretty straightforward. Then we have the sensory part. So in the sensory part, we can have the visual components so we can alter the visual input, maybe quite relevant for ACL rehab as Dustin grooms has already shown. And also my colleague and part of borne, Tim layman has demonstrated that with EEG, that the patient may have some visual reliance, but also things like, do you have your patient do training with shoes on is, are you playing on the hard surface, soft surface lighting conditions, auditory information.
Now those three factors, neurocognitive motor, and the sensory part. What I did in my model, I created like a gauge, so I can create an exercise combination in which I have a relatively simple motor skill. So not so demanding, standing on one leg, for example, but what happens now, if I, and more cognitive load, for example, by having them do math subtractions, or working on the synaptic sensory station by doing motion tracking. Now I can see what the influences is of an added neurocognitive load on my motor art, because those three shape my functional movement coordination. Likewise, I can turn back. My neurocognition lit and stay with the same exercise and do now something on the sensory part. And this is what we all do as clinicians. So we do a single leg balance exercise, and we have the patient stand on on the, on the foam surface, or we have them close their eyes.
So we already doing this, but I think the model can help you. How do I plan my exercises within one rehab session? And I'm changing that from week two week. And why would this be important? Well, first of all, we all always need to consider that we have, we need cognition during our motor control. And if we only work on pre-planned activities that, that are often in happened, we miss something exactly what you pointed out already from the on-field situation. They have to perceive a lot of information. They have to process that information and then execute the movement. And here's where cognition comes in. And we do this by being aware of that, we can use these gauges. What we do is we actually create a rehab environment that we call in part a board. And we call that an enriched environment in which we constantly provide different stimuli to the patient.
That means the rehab from week one to week two is not the same, which means variation, something new, something I haven't done before. Again, this could already motivation so significantly, and I can tell you from experience, patients love this. The second benefit would be since you're providing different stimuli, you actually confronting the brain every time with a new situation and the brain has to find solutions. And this is I think very important also from the motor learning perspective that we need to consider to enhance the neuroplasticity of the brain, because an ACL injury is not just a peripheral ligamentous injury. It is also a neurophysiological lesion and that's, I think, needs to be considered and rehab.
I mean, I, I have to say for me, I really liked this model because it, it gives you a great way. Like you said, to plan out your session so you can maybe enlarge the motor component one day or take it back another day, do more, neurocognition move that back, do more sensory, do sensory motor, maybe not so much neuro do a little bit of all three. So it's sort of like, I just sort of see the Venn diagram, just expanding and contracting with all three of those bubbles, which I think is really great. And like you said, it gives you, it's almost from a therapist standpoint, a clinician standpoint, I feel like it gives me permission to play around and come up with some fun things and be a little more original.
Yeah. And I think what it also does it, it, it may help you as a therapist to get a better understanding where some underlying deficits may be because we only, we T we typically like to measure the outcome. So let's say I'm doing an agility course, and I'm just looking at at the time. And then I see, Oh, the patient is not so fast. So I need to do more training. Well, what you could maybe do is try to untangle a little bit and to see if the patient from the motor perspective has all the necessary requirements in order to be fast. Maybe there's a deficit there, but let's assume it's not the case. So all, all the strength, all the rate of force development, all these parameters are satisfactory. That must mean that there's something else in the system that can't cope with the demands. And that could quite well be that there is an underlying neurocognitive deficit, and this may help you as a therapist to work more on those neurocognitive elements with the intended goal that the patient becomes faster, but maybe not so much, but we're doing more plyometrics and, and doing more speed now working on the neurocognitive aspect.
Yeah. So it's, it's a, a treatment as well as an evaluative tool to kind of see where some deficits are and how you, you and your patient together can plan to move forward. Sounds great. When when will this be widely available?
I hope we have it out in a month, the time from that pending on, on the, on the publication process, but please stay tuned.
Okay, perfect. And we will let, we will let people know. I will put it on social media when that is out. So that sounds great. Well, I mean, thank you so much for coming on and talking about this, I've been taking copious notes. I think this was great. Before we get into where people can find you, I have one last question and I ask everyone this, and that's knowing where you are now in your life and in your career. What advice would you give to your, to your younger self?
Good question. I think what would have helped me if I would have spent more time in the neurological field, I think in, in what I still see, or with colleagues that work with pediatric patients, I think some of the motor learning principles that they use could be very beneficial for us working with more orthopedic sports related injuries. That's something I did not understand back then, because my interests were solely in the, in the sports domain, but in retrospect, I should have spent more time in, in the neurological and pediatric field.
Great advice and great advice for anyone who is maybe at that starting point in the sports or orthopedic rehab world and trying to figure out, Hey, what is there something I'm missing here? So I think that's great advice now, where can people find you and find all this great stuff, all your great info.
All right. So we have a website from our company and our company's serves as the hopefully as the intermediary between academics and the clinical field. I, I work in both fields. I'm, I'm a clinician, I'm a researcher. And with our platform, actually our community model learning Institute, we want to create a bridge between the academic field and the clinical field, because I think we can all improve, but we need to find each other and we need to speak the same language and have respect mutual respect for one another. And if we engage in in such a culture by exploring, by facilitating one another, I think we can create a lot of new things and approaches with the overall purpose to help our patient. This website will be updated in a month from from now. So we will we will be offering completely new courses, which are also have the opportunity to get coaching from us. So it's not frontal education, but we offer for every course participant to receive life or written feedback on their progress during the course, because our premise is that we want to create a course in such a way that you can apply it into your setting after you've completed the course.
That sounds amazing. And we will have links to to the website. We'll have also put the link up to your research gate profile so that if people want to look at some of the papers that you mentioned today, they can just go there and see all the papers that you have authored and co-authored do. I think it would be really helpful. And if people want to find you on social media, where's the best place to reach out to you there
Would be Twitter, Instagram, or Facebook.
Perfect. And what are the handles if you know them off hand motor learning Institute. Perfect. Perfect. Okay. So thank you so much. And like I said, I will have everything available up on the website at pod podcast at healthy, wealthy, smart.com. So Allie, thank you so much for coming on again. I really appreciate it.
Thank you, Karen. And I really want to say, thank you so much for setting this up. I think this is exactly what we also stand for, that we create a platform in which we can exchange our ideas. We can ask one another question that that's the best way I think, to move forward. So really thankful for you to organize this and yeah.
And so everyone, thank you so much for listening. Have a great couple. I have a great week and stay healthy, wealthy and smart. Well, a big thank you to Allie for coming on and sharing all this great information about motor learning as it relates to ACL injury and rehab. And of course thank you to our sponsor net health. So remember on Tuesday, March 9th, net health is putting on a three-part mini webinars series entitled from purpose to profits, how to elevate your practice in an uncertain economy. You're going to hear from a panel of guests that have over 50 years of combined experience working in the PT industry, signups will begin tomorrow, which is February 23rd for this mini webinars series. So head over to net health.com/ let's say to sign up once again, that's net help.com forward slash L I
T Z Y. Thank you for listening and please subscribe to the podcast at podcast dot healthy, wealthy, smart.com. And don't forget to follow us on social media.
526: Briana Zabierek: Turning Frustration Into Fruition As An SPT 0
In this episode, 3rd Year DPT Student at Rosalind Franklin University of Medicine and Science, Briana Zabierek, talks about her DPT Study Guide.
Today, Briana tells us about her experiences in PT school and the frustrations that led her to start the DPT Study Guide. How is the DPT Study Guide helping students? How does Bri find the time to do it all while still studying? She elaborates on the future of the DPT Study Guide, what students can expect to find in the guide and current developments.
Briana tells us about how the DPT Study Guide is compiled, finding her entrepreneurial interest, and she gives her younger self some valuable advice, all on today's episode of The Healthy, Wealthy & Smart Podcast.
How Bri manages her time:
Change of pace: Set a timer for 45 minutes. Put all notifications off, and just zone in on your work.
Master a topic, then move on: Be comfortable bouncing between topics. Master the main ideas before moving on to another topic. Don't try to do a whole topic in one go.
"The long-term goal is not just to provide products and merchandise, but to really make it a place where you know you're stepping into a simplified version of PT school."
"If you have the passion for it, and this is something that you believe in, then you can make anything happen."
"You don't have to be an entrepreneur to make these opportunities possible for yourself."
"Take more breaks and realize how valuable those can be for hitting reset with your mind and focus, and also make time to have some fun."
PT, DPT, Study Guide, Health, Prioritizing, Studying, Entrepreneurship, Efficiency, Physiotherapy, Time Management,
To learn more about Briana:
[caption id="attachment_9507" align="alignleft" width="150"] www.melissa-manzione.com[/caption]
Bri was raised in Lockport, IL. In 2017, she graduated with a BSc from the University of Nebraska-Lincoln, Double Majoring in Nutrition, Exercise, and Health Science, and Nutrition Science with a Minor in Psychology. She is currently studying toward her PhD in Physical Therapy at the Rosalind Franklin University of Medicine and Science, with her graduation expected in May of 2021. Her mission statement: To serve, encourage, and equip patients and students in reaching their full potential.
Follow Briana at:
Facebook: @dptstudyguide
Instagram: @dptstudyguide
LinkedIn: Briana Zabierek SPT
Twitter: @dptstudyguide
Website: https://dptstudyguide.com
https://dptstudyguide.com/downloads
Hi, Bree, welcome to the podcast. I am happy to have you on.
Thank you. Thanks for having me. Sure.
And we'll give a shout out to Dr. Sarah Hague for putting us into contact with each other and telling me all about the great work that you're doing with DPT study guide. And we're going to talk about that today. So before we talk about the guide itself, why don't you share with the listeners, your sort of personal experiences with PT school, which you are still in your third year student at Roslyn Franklin. So share a little bit about your personal experience with PT school and maybe some of the frustrations that came up for you.
Yeah, yeah, absolutely. So first and foremost, I think every student kind of encounters a little bit of a roadblock just starting out between my roommates and just our class itself, we had some pretty good comradery to begin with. And so I always felt that that was a good option to at least discuss, you know, areas that I maybe was struggling with or they were struggling with and just kind of have this like melting pot of different ideas and different ways that we could all just get the job done and kind of figure out what we need to know for exams. But as time went on, I think we all kind of fell into our own little like habits and patterns and maybe a little bit what we're comfortable with. And then what I realized was when I think it was about like the middle of middle or towards the end of first year we had our neuro unit and that is kind of where everyone hit a wall with our study habits and just retaining the information and just kind of collectively as a class, we were making our own separate study guides and they would be like these super, super long word documents.
And I'm talking like 50 plus pages full of yeah. Like eight point text. And I was kind of like attached to them. Like we all would get on like our Google docs and like start typing up information and it just became really overwhelming. And so what I realized was like, I kind of have an opportunity for myself and for my colleagues is to just simplify things a little bit like I was getting sick of kind of going through the PowerPoint slides that were, you know, 120, 150 slides long and just little snippets of information on each. And so I kind of just took a step back and, and saw an opportunity to really simplify things, not just for myself, but something that I thought would be helpful just to transform any student's education going forward. And it was in again, late in our first year when I was inspired by different cash based physical therapists and kind of exposed to that world and realized that there was an opportunity for me to step into like a neat niche position. We kind of get started there kind of with like a side hustle. So that's kind of where everything stemmed from, and right now it seems to be going pretty well. Just looking forward to kind of like sharing the experience.
Yeah. And so tell me a little bit more about the guide itself. Can you kind of give an example of a section of it and how it helps other students? Right.
So one thing that I definitely picked up on when I started posting the information on Instagram, which is my, my primary platform that I use was trying to get the main points of any kind of lecture or chapter into about like eight to 10 pictures on Instagram. And so what I wanted to do was share that information to simplify things for followers and students in general. But the guides themselves are focused around that idea. So kind of finding information that is most relevant to clinical practice and then finding information that's most relevant for board exams, meaning safety, or, you know, most basic like phases of cardiac rehab, pulmonary rehab and stuff like that. And I, I always felt like I mentioned kind of going through so many chapters, so many pages, so many slides it was getting exhausting, trying to figure out what I needed to know. And so the whole point of the study guides is to just really get to the meat and potatoes of everything. And then if you need to find something to reference later on, that's when we obviously go back to our PowerPoints in our articles.
And how are you simplifying or sort of taking out those pieces that you described for the meat and potato pieces. Do you have a system as to how you extract that information from these lectures or is it a group effort? How is that being done? A little,
A bit of both. I, like I said, we collaborate a lot as friends and classmates throughout the years. And then I really actually took the advice from Dr. Sarah Haig. So another shout out to her, she mentioned just go back to the objectives, whether it's the lecture that you're sitting in, in PT school or it's the textbook chapter that really lays out a good I don't know, six to 12 main ideas, and then I go back there and try and figure out, okay, what information from this chapter, can I really pull and fit it into these like umbrella topics? So that's kind of where I started at. And then some of the samples that I have up on the website to reflect like, okay, let's just put the fancy details away. And what do I need to know if I'm seeing a patient or if I'm seeing these questions on a board exam
And what has the response been from your fellow students?
So my class, my classmates are really excited about it. I post a lot of daily questions in, for board exams and they're excited to see it, they've moved their head ideas themselves to start an Instagram just for studying purposes. And then having that collaboration aspect has been really helpful. So I'll even get messages from a few of them saying that, Oh, well, you know, this is something that I haven't gone over yet. So I appreciate you kind of like pushing me to review it and, and stuff like that. But even from complete strangers, like how much support I've, I've gotten has been overwhelming almost, especially with trying to handle studying for boards and preparing for my final clinical rotation overwhelmingly positive. And I kind of attribute that to the field itself. I think going into a profession where we're, we're taught to care for others and put others first and all those ethical principles people are just really grateful to have an opportunity where they can see the information and either like bookmark it and kind of synthesize it right away instead of having to go through all like the dirty work themselves.
So it's been overwhelmingly positive and I just want to shout out to everybody who's following along. I appreciate the support,
And now you hit upon something that I want to dive a little bit deeper into, and that is time. So where are you finding the time? Because I know that I hear from a lot of students that they feel overwhelmed. There's not enough time in the day to begin with. So do you have any tips or tricks that maybe other students or even practicing clinicians can learn as to how you parcel out your time to be able to do all of this?
That is a great point. It has taken me probably the last three to four years, even before PT school to figure out what works best for me. And kind of even coming to the realization of, you know, you, you do need to manage your time before I would be a little bit of a procrastinator. As in like I would, I would start a project and then I wouldn't really finish it. And I was like, okay, well I've already started it. So I'll get to it later. It's almost like more of a, a productive procrastinator, I guess. And so what really has helped me is a change of pace. So I know I don't remember the exact name of the timer, but you either set 45 minutes or 30 minutes where you're just zoned in notifications are off. And you're just focusing on that topic for a little bit.
And then also mixing in a variety. So in the beginning of PT school, I would try and get through all of my lectures that we had that day, the same evening. And that was just that wasn't going to happen. I tried my hardest, but it was just wasn't going to happen. So what ended up doing was bouncing between topics, even if it feels a little bit unnatural. What I've noticed with my classmates and with myself is we want to just master a topic first, before we move on. And I think the most helpful tip that I can give is to really just be comfortable with bouncing between things and just mastering the, the main ideas before moving on to another topic, because the more that you get caught up in the details, the more you're going to kind of lag and again, procrastinate going to other topics. So that is first and foremost, give it some variety, mix things up and then really set a timer. And then lastly, like I said, just taking a peek at the objectives of the lecture and the chapter is really going to tie together, you know, what you need to pull away for clinical practice or, or board examinations.
Yeah, because I think so often we can sometimes get lost in the weeds and we don't pick our heads up to see those bigger pictures. So I think that's really great great advice for students and for physical therapists alike. So now we know why you started DPT guide and now have a better idea of what it is. So my next question is what, what is the goal for you of the DPT study guide
First and foremost, I, I want to make it a community. I think the longterm goal is to be not just to provide products and merchandise, but to really make it a place where students and practitioners alike can come and just review without any, I dunno, egos or preconceived notions or anything like that. Just coming into a place where like, you know, you're, you're stepping into just a, a simplified version of PT school or PT practice. So that's the ultimate goal is just making a community for people to come together and not, not entirely making it about DPT study guide, but making it about the appreciation and respect for physical therapy itself. I do a lot right now on the page about daily, weekly posts covering a variety of topics, as well as sharing a lot of other students, other clinicians work that they are doing to promote the profession, promote their small businesses. And so that's, that's kinda, my, my longterm goal is to just make it this safe space, I guess, for PT students and clinicians alike.
And now is this something that is meant to help people pass their board exams? Cause I just want to make sure that we're kind of differentiating so that people, especially students that are listening if they want to get this guide or get these guides from you, is this something that's like, you're gonna pass your boards if you do this. Cause I don't want there to be any information there.
Right? Absolutely. My first line of products is geared towards the board exam, especially the MPTE. I think long-term, I would like to branch out and see, especially in Canada, my boyfriend is Canadian. So you kind of giving some respect, a little shout out there too. But first and foremost, yeah, it's going to be focusing on the MPTE and then down the line I would like to extend it into just clinical practice, you know, how things have evolved from our standardized examination to how things are in the clinic or in the hospital.
Got it, got it. Okay. So what can people expect? What if I, if I am a student and I want to download this, what can I expect to find,
Do a lot of aesthetics? So I try to pull in like I said, the information that is relevant to both clinical practice and board examinations by kind of seeing where the attention is going to be in terms of like the mind's eye. So transitioning from what we made in school during our first year with those 50 to 60 page documents with just white background, black text, it's really hard to find the information that you think is going to be important. And kind of just simplifying it into basic examination procedures, basic interventions phases of rehab medical screening, laboratory values. And like I said, kind of the meat and potatoes of everything that PT is just so that students don't get overwhelmed with the details. It's going to be like bright and bold big ideas and then kind of like,
Got it, got it. And, okay, so now we have a better idea of where you would like this to go. So tell me, what else do you have in development? What are you thinking that you can add to this? And it looks like, so what I mean, when you're on the website, it looks like it, the addition to it is, can be infinity. So I think it's important for people to know that it's not like you go onto your website and it's one big gigantic guide. Right, right. So where do you see this going? What do you have coming down the pipeline?
So first and foremost is getting out both PDF copies and paper copies of the study guides. And then once I feel like that has a pretty steady response rate, then I want to transition into maybe even tutoring one-on-one video instructions or even student courses where they can go through maybe a differential diagnosis and orthopedics or differential diagnosis medication review in neurology and even down the line. This is like probably five years from now. I have a very invested passion and pain science, and so kind of pulling those things together and offing offering courses for professionals and students alike. So I, I have high hopes. I think it's going to be a little bit of a learning curve and seeing what the demand is for students and professionals when the time comes. But I, I have full intentions to continue to grow with the demands that are out there for students and professionals.
Awesome. And now, you know, this is obviously very entrepreneurial and which is very exciting. So where did that spark come from? Because not everyone has that kind of entrepreneurial spirit and nor do you need to have it to be an excellent physical therapist, but where did that come from for you
First and foremost? I have to, again, shout out to a dear friend of mine. His name is Travis. Robertson. He is, he was a third year student when I was a first year student. And like I mentioned, during that neuro unit where things kinda got a little hazy with studying, he mentioned to me that like, you know, why don't you just take a chance and see what the market is out there? He was very invested in cash based physical therapy at the time. And so then I started looking into, I mean, all the major ones, Aaron LeBauer was first and foremost, Danny Mada, Jared Carter. I actually even kind of more on like the female entrepreneur side of things is when I found obviously Karen Lyndsey and Dr. Hague more, just more opportunities to see what those people were doing in their own journeys.
And so he really inspired me to just take a peek at what's out there. The more that I learned about cash based businesses, owning your own PTP clinic, the more I realized that there's different opportunities with side hustles with other income streams. And that's when I, I kind of took my passion for simplifying PT studies into like the study guide form and realizing it's going to take a little bit of effort upfront. But you know, if you have the passion for it and if you feel it's like, it's something that you believe in and fit that this is truly something that I believe in, then you can make anything happen. Like you said, you hit the nail on the head. You don't have to be an entrepreneur to make these opportunities possible for yourself.
Yeah, no, definitely not. Definitely not. As long as you can stay organized and motivated and at some point reach out for help. I know not necessarily in the beginning, but you know, as time goes on reaching out for help when you need it is always a great thing as well. Well, it sounds like you've got, it sounds like you've got everything under control. I think you might be more organized and, and, and you've got your, you know, what together, more than I do. So I may, I'm a little so now what, where can people find you? Where can they find the guide? Yes.
So the website is plain and simple DPT study guy at.com. I also run primarily the Instagram account, which is the handle is DPT study guide. And then that same handle you can find on Twitter and Facebook. If you're interested in connecting to me personally I do have a LinkedIn as well, and that would be my first and last name Breeza Barrick. So we can connect there too, but yeah, everything is easily accessible from the website and from Instagram page.
Awesome. And, you know, just so you know, it's also very easy to download and it is very pretty and it's very organized and looks very it looks great. So I highly suggest if you're listening to this, especially if you're a student and even if you're not, if you want to brush up on your open and closed pack positions for all your joints, definitely a check out to DPT study guide.com. Now the last question is something I ask everyone it's knowing where you are now in your physical therapy student journey. Normally I say, in your life and career, what advice would you give to yourself right out of PT school, but why don't we say, what advice would you give to yourself maybe before you started physical therapy school to where you from, where you are now?
Oh, that's a great one. Looking back, I would make more time for breaks. I feel like students are way too hard on themselves in terms of, I need to be studying 24 seven. If I'm taking a break, it makes me weaker. It makes me less smarter or whatever the case may be. Take more breaks and realize how valuable those can be for just hitting, like reset with your, your mind, your focus. And also just making time to have some fun. I, I really feel that our class emphasize that a lot because we were also motivated to perform as best we could on test exams and really trying not to sweat the small stuff. Obviously, like I said, the whole goal of it was to let's focus on the big picture and maybe try and make it a little bit easier on ourselves throughout the way.
Excellent advice. Excellent. Well, Bri, thank you so much. You are absolutely wonderful and makes me very excited for the future of our profession, knowing we have people like you getting ready to graduate and enter the workforce. So thank you so much for coming on the podcast.
Yeah. Thank you so much for having me. I really appreciate it.
My pleasure, and everyone, thanks so much for listening. Have a great week and stay healthy, wealthy and smart.
525: Dr. Nicole Surdyka: Return to Performance After ACLR 0
In this episode, Director of Rehabilitation at OL Reign, Dr. Nicole Surdyka, talks about on-field rehab after ACL injury.
Nicole is currently the Director of Rehabilitation at OL Reign, one of the founding clubs of the National Women's Soccer League, NWSL, which is one of the best professional women's soccer leagues in the world.
Today, Nicole shares her 5-phase on-field rehab strategy, and the decision-making process in return-to-play and return-to-performance. What are the criteria that Nicole looks at to determine progress to the next phase of rehab? She tells us about delaying return to sport to reduce second-injury risk, the return to sport continuum and how to define it, and the use of the StARRT framework for the return-to-sport decision-making.
Nicole gives some valuable advice to her younger self, she tells us about integrating rehab with team activities, and communicating with athletes and coaches, all on today's episode of The Healthy, Wealthy & Smart Podcast.
Nicole implements on-field rehab in 5 phases.
Phase 1: Simple, pre-planned, linear movements. The focus is on quality of movement and cleaning up movement technique before moving on. Typically includes walking marches, walking lunges, side shuffles, and jogging. Nicole starts this at 70-75 quad strength limb symmetry index.
Phase 2: Pre-planned direction-changing movements. Typically includes accelerations, decelerations, sprinting, and change direction.
Phase 3: Adding reactive tasks without a soccer ball. Direction-changing with an element of reacting to an external event. Nicole starts this with at least 80% quad strength limb symmetry index.
Phase 4: Soccer-specific movements. The reactions are done in context – with a soccer ball.
Phase 5: This phase should look like a modified training session.
Delaying return to sport: each month that you delay that, there's a 51% reduction in second-injury risk, up until the 9-month mark.
Return-to-participation: When athletes are participating in their sport in a modified way – participation with certain limitations on activities.
Return-to-sport: When there is no longer any medical reason to limit an athlete's participation – "cleared to play".
Return-to-performance: There are no restrictions and athletes are training to become better at their sport.
"Be patient. Every experience is valuable, and you can relate any experience to what you eventually end up doing."
On-field Rehabilitation, StARRT, Injuries, ACL, Sport, Performance, Physiotherapy, PT, Therapy, Wellness, Health, Injury-Prevention, Recovery,
Consensus statement on return to sport: https://pubmed.ncbi.nlm.nih.gov/27226389/
On-field rehabilitation Part 1: https://pubmed.ncbi.nlm.nih.gov/31291553/
More about Dr. Surdyka:
Nicole is a physical therapist and strength and conditioning coach. She played Division 1 college soccer at St. John's University and then went to Emory University where she got her Doctor of Physical Therapy Degree. Throughout college and PT school, Nicole coached youth soccer and worked as a personal trainer.
After PT, school Nicole worked in various outpatient orthopaedic and sports medicine clinics before starting her own practice in 2018 where she worked with youth to professional athletes. Nicole specializes in on-field rehab for soccer players to help bridge the gap between rehab and sport performance. She is passionate about the return to sport process and how we can make better decisions for athletes returning to sport after an injury.
Nicole has a website where she writes blog posts on rehab for soccer players, has eBooks available on specific injuries, teaches continuing education courses, and has presented at CSM and other national and international sports medicine conferences.
To learn more, follow Nicole at:
Website: Nicole Surdyka Physio
Facebook: Nicole Surdyka Physio
Instagram: @dr.nicolept
LinkedIn: Nicole Surdyka PT
Twitter: @NSurdykaPhysio
YouTube: Nicole Surdyka
Read the transcript here:
Hey, Nicole, welcome to the podcast. I am so excited to have you on.
Thanks. I'm excited to be on.
So this whole month we're talking about ACL injury and ACL rehab, and you are an expert in both. So I'm really excited to have you as one of the guests this month. And today we're going to be talking about something that is really your zone of genius, and that is the on-field rehab, a rehab techniques, I guess, that helped to bring that player back to performance. So can you talk about what is the on field rehab like?
Yeah. So I guess it's a concept that I, you know, I was a soccer player. I was a youth soccer coach, and so I always kind of felt in the back of my mind when I was going through PT school, like, Oh, wow, I could blend. Like, if, if we're trying to get this adaptation or build up this physical attribute, we could do that through soccer. And so it just made, it was something that made sense to me trying to incorporate the sport as much as possible, but where it really all clicked and came together. For me, it was actually at the isokinetic conference that I went to a few years ago in Barcelona. And actually your previous guest on this in Arundale was the one who talked me into going. So that was great. And I saw a presentation by Matt Thorpe about on-field rehab. And of course he and Francesco via have published two different articles in WSPT on this, but kind of seeing that presentation really yeah, tied it all
Together and made me have that aha moment
Like, Oh, this is a thing I can make this happen. And so really what it is is it helps to bridge that gap between the gym-based rehab and then sending the athlete back for their sport. Because if you think about it, there's so much of a difference between doing a drop vertical jump in the gym and then landing from a head ball on the field. Like not even just physically that's different because the surface is different. Your shoe wear is different. The weather obviously is different, but there's also different things in your environment to make decisions based off of, and react to and respond to. So where are my teammates in space? Where is my opponent? Am I going to have a contact or an indirect contact, a perturbation while I'm in the air that I have to land on? Funny, where do I have to redirect my Ron to afterwards?
And you can only prep for that so much in the gym. And at some point you really need to get them on the field and do in a controlled way, what they're going to have to do when they're playing with their team again. So on-field rehab. The way that I implement it is really based off of Matt, Matt backdoor, Ben for Jessica, Davey is research and there are papers on it, which is phase one, really simple pre-planned linear movements. And so that can start fairly early. They say in their paper that they want to start. When the athlete has 80% quad strength, limb symmetry index, I tend to start a little bit earlier than that. Typically, when I'm having athletes jog, then they can be doing phase one. So things like walking marches, walking lunges side shuffling is okay in this phase, jogging anything that the athlete is has pre-planned, it's a pre-planned movement and it's just linear.
So no changes of direction yet. And in this phase, we really focus on quality of movement. And we start to address here before they move on to more complex tasks we address are they moving efficiently? And are there things we need to clean up with the technique of their movement? So something like a high skip or a walking March, are they getting a lot of trunk lean? Are they yeah. Are they kind of like looking like Gumby out there? And so we need to clean that up a little bit, and this is the phase that we can really take the time to do that. So again, I like to start this pretty early. Typically I want them to be at least 70 to 75% quad strength, limb symmetry index. But the, just as a caveat to that, the paper by Francesco and met, like they're up says 80%.
So just be aware of that phase two, they then move on to being able to change direction. Everything is still pre-planned. So we can take those linear movements from phase one and make them a little bit more intense. So we can start working on reaching towards accelerations decelerations, maximum speed. So we start to work on sprinting here and exposing them to high-speed running on the multi-directional staff. We can have them do anything pre-planned so no reactive tasks yet, but they can start to cut decelerate, changed direction, all controlled everything throughout the unfilled rehab program is control first. Then we build volume and intensity. So after phase two, we can progress them to phase three. Now for this, I definitely want them to be at least 80% quad strength, limb symmetry index. And I would love for them even to be closer to 85% and depending on how they look functionally.
And so this is when we start to add reactive tasks. So now change of direction tasks, but with a reactive component. So they're reacting to something external to them. So I like to mix up and I know Amy talks about internal versus external cues a little bit. And it's something that definitely is coming up a lot in ACL research with motor learning is that we want some external cues. And so that can be auditory. That can be visual. So I like to do kind of a combination of both. I'll use words that they're going to hear while they're on the field. So turn man on ball, you know, I'll use kind of those that verbiage. And then the visual is you can make it just simple. You pointing to where they have to cut to or change direction to. You can make it be, they have to follow the ball, they have to follow a runner.
So they have to follow where the space is that you've set up with, however, you've set up the environment. So that's where we add the reactive components and they anything pre-planned they can now be doing at speed. Next, we're going to go into phase four, which is really going to be more soccer, specific movements. So now they can react with a soccer ball. So everything we didn't base three with the reactive movements is them without a ball at their feet. Now in phase four, we can add a soccer ball. So you have to turn and either dribble, dribble, or pass, or you know, you have to collect the ball and then make a decision based on what's going on around you or what the coach or the physio calls out. And then phase five really should just look like a training session, a modified training session. So I try to replicate what the team has done in their training session or what a typical team training session would look like as much as I possibly can within a more controlled environment. So that's kind of the five phases and then, yeah, and then I started to incorporate them into the team. Okay.
So let's, I have a couple of questions. So we're just going to back up a little bit. So for most of these phases, certainly phase one phase two phase three is the player is the player alone on the field? Do they, are they working in tandem with another player on their team?
So typically when I was, before I had my current role, I had my own practice and I would work with the athletes. So it would be me and the athlete. If they had a friend or a teammate who was available, it's always nice to add other players. Now here at LL rain. I have two athletes right now who are going through ACL rehab together, kind of they're at a little bit different spots, but I can still work together with them, which is really nice. And then I can always pull some of the other players. So, Hey, do you want to work on crossing and finishing today? Great, like come in for this session this time and I can pull other players and you can do it alone. Eventually you need to start adding other players because there's 22 people on a soccer field. And so they need to start being able to move and react to all of those different people on the field, around them. And you can still do that in a controlled fashion. Absolutely.
I will say to, to play or one, I want you to run down to line and cut to the right as your athlete is within the midst of whatever you're asking them to do from a rehab standpoint. Correct.
Exactly. You can say, okay, you're going to run up and defend them. I want you to force them to their right. You know, so that way I have that person has to go to their right, so you can control for it. Whereas in a game you can't tell them, or an even in a practice session with their team, you can't say to all the other players on the field, Hey, when you go and defend, so-and-so only for, for her to her right foot, okay. That's never going to happen, but in that nice in on-field rehab, you can control for those things. And
The other question I have was what is the criteria for entering phase two?
Good. So, and answering into any onto three high program. I mentioned the quad strength, limb symmetry index, but also there should be no joint pain or a fusion. They can have some muscle soreness at times if they had a patella tendon graft they can have some patella tendon pain. I'm okay with that. Hamstring graft, if they have hamstring pain, I'm okay with that. But, and then also no joint laxity. So I'll typically just do a Lockman's anterior drawer test, as long as those are negative and there's no joint fusion, then we're good to go. Now it's progressed through each stage, subsequent to that, as long as they're able to do those movements with control, and there's no increase in joint pain or a fusion during any of those stages, then I can progress them. Although I still want to bear in mind, like we're not just going to do walk like phase one stuff.
And then it's like, Oh, they felt good. Okay. Now we can do phase two. Like I still want to make sure that we get a couple sessions in and it's always going to play back into the overall big picture of where they're at in their rehab. You know, we're still doing a gym-based strength program at the same time that we're complementing with on-field rehab. So it that's where it kind of the the art of coaching takes in a little bit. And you just need to understand where your athlete is and if they still need more time in that area before moving on. Got it. And
I know this is a question that a lot of people constantly ask when it comes to ACL, what is the timeline? Right. You know, cause you're always here. You don't want to return to play for a year for 10 months, nine months, a year, two years. So as you are going through these phases, are you also taking into account where they are in that rehab continuum or in, you know, post-surgical so how do you question
W so it's kind of the, the short answer to that question is we can go back to some of the research that's been done by the Delaware Oslo cohort, so that, Hey, grandam over at Oslo and Lynn center Mackler at Delaware, and they've shown that delaying return to sport each month that you delay that there's a 51% reduction in second injury risk. And really the whole thing of this is when we're sending out fleets back to sport after an ACL reconstruction, our goal is to not allow that to happen again, right? The rate of a secondary injury is so high that there's obviously a flaw in how we're sending athletes back. So I think that most athletes go back too soon. And so each month that we delay up until the nine month Mark and at nine months, we, after that, we don't really see that level of reduction in, in, in second injury risk.
Now for a youth player, who's not really in a rush to get back. I will probably never let them go back before a year. I just, there was no reason it's not worth the risk. They're agreed so much more likely to have another injury. And like, why have two ACL injuries in high school before you even get to college? Right. If the goal is to, is to play in college, you're better off missing your entire junior year of high school to just rehab and then be really strong for your senior year. As opposed to feeling like, Oh, I have to show college coaches. I have to go to all these college showcase tournaments, which I know is, is pressure on the athletes, but what does it, do you any good if you go back and now you do it again and you miss all of senior year as well, right then by college, like that's not going to happen for you. Right. So more of the professional athletes, there's a little bit more pressure, it's their livelihood. Right. So I'm okay with moving or even college athletes. I'm okay with moving closer to nine months, but I will never go before that, unless I have somebody like an Adrian Peterson who is just one of those outliers, then they have to give me a really good reasons to let them go back.
Okay. And this actually flows perfectly into the next topic I wanted to talk about. And that is that decision-making for return to performance, right? So we've got the return to play. And even if you want to talk a little bit about that distinction between return to play and return to performance and talk a little bit about what your your decision-making
Is like. Yeah. So to talk about that continuum a little bit, and actually I just had a meeting with our coaching staff here about that to make sure you're on the same page about these definitions. And so how I define them is based off of the return to sport a consensus statement for that Claire and was lead author on where the return to participation phase is when, or end of the continuum is when athletes are participating in their sport, but in a modified way. So I have a couple athletes now who I say, I look at what the daily session plan is for, for the training session. And I'll say, okay, this athlete can do the technical warmup and they can do the [inaudible], but I don't want them doing the two V twos because it's too much deceleration cutting, et cetera. So they, that counts as returned to participation because they're participating, but I'm still putting restrictions or limitations on them.
So anytime there's any kind of modification or restriction or limitation there in returned to participation, when the medical, when there are no longer any medical reasons to hold an athlete back, that's when they're in return to sport. So that's what I would define as saying like you're quote, unquote, clear to play, right? Is that I'm not putting any restriction on you, if you are not being selected for playing time or for your starting position. That's because the coach isn't selecting you, not because I'm holding you back, but then beyond that, because sometimes an athlete's not going to really be satisfied with that outcome, right? If you're used to being the starting center forward and scoring a goal, a game, and now you're cleared, but you're not being selected into the starting lineup, or you're not being selected to the game day roster, or you are, but you haven't scored a goal in five games.
Now you're not performing at where you were prior to your injury. So there's no medical reason to hold you back, but maybe you're not playing as much or playing as well as you would like to be. And that's where we transition into return to performance. So return to performance is there's no restrictions on you, no medical limitations or anything holding, holding you back from a rehab perspective. And now we're training to get you to being better at your sport. And I think those are really important distinctions to make, because a lot of times athletes or coaches, and actually it will be back and cleared to play, but coaches like, well, why isn't she as fast as she used to be? Why isn't she scoring goals? Like she used to be? Is she still hurt? It's like, no, it medically fine, but we're just not at return to performance yet.
So then to to kind of decide when to send an athlete back for each of those things, I tend to look back to the on-field rehab program and how that is structured. So I'm a big fan of integrating the team, the athlete into team activities as often, and as much as you possibly can. So if they're able to do the technical warmup with the team, I'm putting them in there because, and that would technique that would typically be if they're in stage two, right. Cause it's going to be mostly pre-planned change of direction tasks, maybe some accelerations D cells, depending on, on what the warmup looks like. Sometimes there's reactive components. And so that sometimes takes just a conversation with the performance director or the SNC coach or the sport coaches, just to say, what is involved in this? And then, you know, but if you, if that athlete is able to do those things and they've done them with you and an on-field rehab program, send them back into the team.
Cause that is just to me is another level of like the cognitive awareness and their ability to see what's going on on the field, around them and adding more athletes into the mix that they have to interact with. So I'm a big fan of that. So I'll typically have them in that return to participation phase for a fairly long time, like a few months before I say, okay, you're good. So, and the example right now, I have an athlete, who's doing portions of training sessions, but I probably won't like clear her quote unquote, clear her to play in a game until somewhere in the middle of April. Right. So she'll be,
Is she about like six months then? Post ACL? Yeah. Yeah. Yeah. Okay. Yeah. And I think it's important to mention all of this because oftentimes a lot of physical therapists and I, this is not to throw our profession under the bus or anything, but a lot of physical therapists tend to be a little bit more restrained. They won't want them to go onto field. They won't want them to do this on-field rehab until they're at 90%. Right. And or until the doctor clears them to return to play well, you can't just be cleared to return to play. And you've only done a weight training program, proprioception, maybe some motor control stuff and then throw somebody on a field.
Yeah. And I've seen that way too often.
Yeah. Yeah. And so it's, I think that I'm really happy that you're saying like, Hey, you know, at six months they can be with the team, they can do some things. It just, it sounds to me like it's a lot of communication and collaboration from the, all of the stakeholders, right?
It is, it does take a lot of communication. And we have twice a day meetings, constant emails, constant communication about where each athlete is. And then, you know, there is things that come up that we have to adapt to, like this was the training session plan. And this athlete was going to be able to do this amount of load that day. And then based on what was happening in the session, the plan changed. And so we have to adapt to that. And then we just supplement that with it with more on field work, you know, if they weren't able to do as much in the session with the team, then I just will take them to the side and do more work with them on the field. Now I will say that this is a lot easier to do in a team setting. And now I didn't work in a team setting for most, all of my career up until very recently.
And so what I did in that situation, working in an outpatient clinic, that doesn't mean that this doesn't apply to you because you can still use this. And so what I used to do is whatever I would see my athlete do in the clinic with me or on the field with me, I would say, okay, I want you to go do this in practice with your team. So I want you to do the dynamic warmup with your team and then that's it. And then report back to me if that felt okay for them, then I'll say, okay, you can do any technical drill. You can do rondos, you can do, you know, possession style games but no contact. You can be neutral player. And I'll tell the athlete that depending on their age, I'll also tell their parents I do or did before I was in my current, always try to reach out to their club coach or their high school or college coach and let them know what the restrictions were. I understand sometimes we don't get responses when we reach out. I didn't always get responses when I reached out. But as long as you talk to the athlete and or their parent about that, and just make it very clear to them, like you can do this, you can not do that and then have them report back. But I, my rule of thumb was I wanted to see them do that type of activity with me before I had them do it with their team.
Makes sense. And, and I think it's also important to note that just because you work in an outpatient clinic, doesn't mean you can't take these athletes onto a field. I live in New York city. I see patients in their home. I have a 14 year old who had a ACL rupture and subsequent surgery. And when she was 12 she's 14 now. Wow. Yeah. And we still got her out onto a field, got her. We went to the park, we did as much as we could on field. And sometimes that was just me having to be the defender or setting up cones and having her do stuff. But I think it's really important that if you work in an outpatient clinic, don't kind of wall yourself in with the walls literally. Yeah, exactly. You can take them out onto a field somewhere. I mean, if I feel like if I can do it in the middle of Manhattan, then people could probably have a much easier time doing it in places with more space.
Yeah. And I would even get like, I've worked in clinics where the only space we had was the parking lot. And maybe that's where we did that. Or again, you can always say like, okay, I've, we've done the 11 plus warmup in our, in our gym based sessions. So you can go do that with your team now. Or we've done some volleying and passing and moving, you just need 10 yards of space. Right. We've done that in the clinic. So now I want you to try that with your team, or can you go in the backyard with your mom, dad, sister, brother, whomever, teammate, friend. And I want you to do these types of exercises in your backyard, you know, like have that be their AGP instead of having them do straight leg raises for six months. I mean, I have that either ETP.
Yeah. I had my patient probably much, much to her. Neighbors' dismay, but we would be in the hallway of the building. Yeah. Or go into the basement of a building. I see a girl now for she's a softball pitcher. We go into an empty storefront. That's kind of attached to the building. I mean, you make it work, you know, you just have to
Exactly. And like, if you can't find a way to make it work, you have to ask yourself, should I really be working with this type of athlete? Right. If you can't find a way to give the athlete what they need to get back safely and appropriately, then maybe that's not the setting, the athlete to be seeing you.
Right. So it's you do the, I call it the blessing release. Oh yes. More, you need more space, you need XYZ. So I'm going to release you to someone that can, can finish the job if you will.
Exactly. And that takes, like, I feel like in all walks of life, like just not having an ego is such an important skill set to have. And just saying, I know that there's so much more that can be done for you. And I know that there are too many limitations on me to be able to do this. So here's someone who can help you and you should move on to this person.
Yeah. Yeah. And I think that's fair. And again, patient centered. And when you think about that return to sport, decision-making a lot of Claire, our Dern's work is that patient centered decision returned to sport decision-making. And so what you just said is exactly that. And so I think it's important for people listening that it may not always be you. Yes. That is such an important point. Yeah. Now, is there anything that we missed or that I glossed over that you're like, Oh man, I really wanted to make this point. Did we hit everything? Yeah. We hit everything.
The only thing I would add is just as something for people to maybe go look up and learn more about is in that consensus statement, they talk about the start framework and that's what I use to guide my return to sport. Decision-Making right. So it's really just a simple needs analysis. What are the demands that this athlete is going to have to face and are they prepared for those? And yeah. So the start framework is a really great method. It's what it's literally what I use to help guide decision-making because it doesn't just look at, like, it looks at the tissue health, it looks at the demands. It also looks at what are some modifiers of those. So is it preseason? And so we can err on the side of being a little conservative or are we in the playoffs and this is one of our star athletes and we need them on the field. And so we're willing to take a little bit more risk. So yeah, I think that that's a really important framework to utilize because it provides you with that context that surrounds the kind of the risk reward ratio.
Exactly. Yeah. And that's what I said to my, this 12 year old, who's now 14, but you know, she, we waited a year, at least a year for return to sport and then COVID hit and that night Oh yeah. Which I have to say, I wasn't mad about two years, you know, that's awesome. But you know, like what I told her was exactly what you she's like, Oh, do you think I can like play in this, you know, showcase she's an eighth grade. Yeah. No Roland showcase. And I was like, listen, here's the deal. Can you do this? Yes. Will you be at your best? No. Are you going to college? Is if this, what? And I said, it was like, if this was your senior year and it was the last game
Sure. Have at it, you know,
But it's not, so you're not going to do it. Are we in agreement there? And, and that's the hard part, right. Is trying to say to like a 12 or 13 was 13 or 14, 13 maybe was, do you want to play in high school? Yes. Would you like to play in college? Yes. Well then you don't need to do this exam because we're not taking any unnecessary risks and that's kind of, how did that start framework is looking at that context and I'm sure you have those difficult conversations all the time.
All the time. Yeah. It, and especially after something like Nazi has already been cleared by a physician or previous physical therapist or athletic trainer or whomever, and then it's like, Oh no, I know that you were cleared, but we'll, you are certainly not ready. And just having that conversation can be difficult, but as super important, because all they're going to do is go right back. And the likelihood of them getting another ACL injury within the first year or two is pretty substantial. So sometimes scare tactics, work a little in that regard.
And it's not, it's just, you're just being honest. Yeah. Like you can't like, you're the professional, you're the expert. They're the patient they're going to you because you're the expert. Yeah. Right. And so you have to be honest and you have to be upfront and you have to give them all of the options that they have and looking at things realistically, because just, you know, people say, Oh, runners, they just want to run. Well, it's the same with any sport soccer players. They just want to play soccer, football, I just want to play. And so there there's a lot of mental gymnastics that can happen in one's brains in order to justify doing that.
Definitely. I think athletes actually appreciate that when you say like, like maybe in the moment they're frustrated, but it's not with you. It's just with the situation. And I think that makes it easier to swallow is that like, Hey, like they appreciate knowing that you're taking that context into consideration. Like, say like, Hey, if you're going to get re-injured, it's going to be in the championship game, not in a preseason friendly, like what sense does that make? And I think they do for the most part, appreciate that and understand it. Even if, again, in the moment it frustrates them a little bit. Yeah.
I mean, there's a little bit of disappointment, but you know, something it's upsetting
Templating moment. Get over it. You'll be fine. I feel the same. Exactly. I've never said that, but in my head I'm like, you'll be fine. You'll be to sign. Yeah. Like 10 years. That's fine. If you do it again and have to go through another year of this
Exactly. Like 10 years from now, you're not going to be like, man, I didn't get to play in this showcase when I was in eighth grade.
Yeah. Definitely not. It doesn't make sense.
So I think thank you for bringing up that start framework and we'll try and get links to all of this and put them into the show notes so that everyone if you're looking for those papers on on-field rehab, the start framework and the consensus, we'll get all those and put them into the show notes. So you one click and everybody can read all of them. So Nicole, before we end our talk is the question I ask everyone. And that's knowing where you are now in life and career. What advice would you give to your younger self?
I would definitely tell myself to be patient. I came out of school thinking like, okay, I just want to work with athletes. You know, I have to find a place where I can just do that. And anything else I do is a waste of time. And what I will say, what I would tell myself is that every experience is valuable and you can relate any experience to what you eventually ended up doing. Even working with a, you know, if it working with the elderly population that has nothing to do with working with athletes, but teaching them a new skill. If you can teach it an older person, who's never worked out a new skill, you can teach an athlete, a new skill, right. It's somebody who's like coordinated and strong and athletic as opposed to an older individual who's never worked out before. So I think that I would tell myself again, just be patient there's value in every experience and yeah, you'll, you'll eventually get to what you're looking for. Just take it, take things in stride and learn from each experience.
Excellent advice. Now, where can people find you on social media? I think you've also got an ebook available. So give us all the goods.
Yes. So you could to reach out to me. I'm I'm on social media. Instagram is at Dr. Nicole PT. My Twitter is at Encirca physio and my website is Nicole Serta, physio.com. I have a blog there that I grew up on this. I'm going to try to write more. I took a little hiatus. You had,
I had a major change of life yourself from California to Portland and a new job. And so I think we, we understand we'll give you
We're in the middle of a pandemic. So yeah, I think somewhere in the middle of the Vietnam, I just kind of lost a little motivation there
With you all.
Okay. It's okay. There's no need to like, feel guilty if you're in the same boat, cause I'm right there with you. But yeah, I will be writing more on that blog. I have actually a couple of different topics on the blog. One is just kind of rehab of soccer related injuries. And then I talk about some of the social issues related to soccer, things like racism and soccer and inclusion and diversity and things like that. And then also I have this little fun part. That's kind of just for me as a little self-indulgent, but life lessons that I've learned through soccer. And so that's on there as well. I also have some eBooks on my website. You can get to just by going and Nicole Serta, physio.com and it's under the eBooks tab. So on an ACL injuries, ankle injuries maybe hamstring injuries too. There's a couple on there now. Awesome. yeah, that's it. Excellent. Well, Nicole,
Thank you so much. This was great. I great addition to our month on ACL injury and rehab. So I thank you very, very much. Thank you
For having me on carrying this. When I graduated PT school, this is the first PT podcast I started listening to. So it's awesome to be on it. It's come full circle. It truly has. Yes.
Well thank you and everyone. Thank you so much for listening. Have a great week and stay healthy, wealthy and smart.
524: Dr. Amy Arundale: How to Decrease Risk of ACL Injuries 0
In this episode physical therapist, biomechanist, and researcher,Dr. Amy Arundale talks about how to decrease the risk of ACL injury.
Amelia (Amy) Arundale, PT, PhD, DPT, SCS is a physical therapist and researcher. Amy is transitioning to a new role as a physical therapist at Red Bull's Athlete Performance Center in Thalgua, Austria.
Today, Amy tells us about injury-prevention programs, communicating with different stakeholders, and helping empower athletes through education. We also get to hear about her recent publication on Basketball, Sports medicine, and rehabilitation. How does motor-learning, creative thinking, and problem-solving relate to ACL injuries?
Amy tells us about implementation and compliance with injury-prevention programs, internal versus external cues as they relate to injury prevention, and the gaps in the research, all on today's episode of The Healthy, Wealthy & Smart Podcast.
"We've got great information. We know these programs can work, but for them to work, you have to do them."
"You may be a physio, and you may have this injury-prevention knowledge, but you don't have to be there for this to happen. It's just as effective for you to run this program as it is for a coach or a parent to run it."
"It's exciting to see where this next generation is going to be because I think we're going to have some athletes that are more empowered to know more about their body."
"We need to be better at reporting our biases, looking at our subject populations, and funding and encouraging studies outside of 'the global North.'"
Giving yourself the space and kindness to recognise that you don't know everything and make it a point to learn more is good therapy.
More about Amy:
Amelia (Amy) Arundale, PT, PhD, DPT, SCS is a physical therapist and researcher. Originally from Fairbanks, Alaska, she received her Bachelor's Degree with honors from Haverford College. Gaining both soccer playing and coaching experience throughout college, she spent a year as the William Penn Fellow and Head of Women's Football (soccer) at the Chigwell School, in London. Amy completed her DPT at Duke University and throughout gained experience working at multiple soccer clubs in the US and Norway. Amy applied this experience working at Balance Physical Therapy providing physical therapy for the Capitol Area Soccer Club (now North Carolina F.C. Youth) and the U23 Carolina Railhawks. In 2013, Amy moved to Newark, Delaware to pursue a PhD under Dr. Lynn Snyder-Mackler. Amy's dissertation examined primary and secondary ACL injury prevention as well as career length and return to performance in soccer players. After a short post-doc in Linköping, Sweden in 2017, Amy joined the Brooklyn Nets as a physical therapist and biomechanist as well as The Icahn School of Medicine at Mount Sinai Health System as a visiting scientist. Currently, Amy is transitioning to a new role as a physical therapist at Red Bull's Athlete Performance Center in Thalgua, Austria. Outside of work, Amy plays Australian Rules Football for both the New York Magpies and US National Team.
Amy has also been involved in the APTA and AASPT, including serving as Director of the APTA's Student Assembly, a member of the APTA's Leadership Development Committee, chair of the AASPT's Membership Committee, and currently as a member of the AASPT Diversity and Inclusion Committee.
ACL, Injuries, Recovery, Injury-Prevention, Learning, Sports, Physiotherapy, Research, PT, Rehabilitation, Health, Therapy,
https://bjsm.bmj.com/content/54/21/1245
To learn more, follow Amy at:
Instagram: @squeakyedgar
LinkedIn: Amelia (Amy) Arudale
Twitter: @soccerPT11
Welcome to the healthy, wealthy, and smart podcast. Each week we interview the best and brightest in physical therapy, wellness, and entrepreneurship. We give you cutting edge information. You need to live your best life. Healthy, wealthy, and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now here's your host, Dr. Karen Litzy.
Hey everybody. Welcome back to the podcast. I am your host. Karen Lindsay, and today's episode is brought to you by net health net health therapy for private practices, a cloud-based all in one EMR solution for managing your practice. That's right. One piece of software that handles all of your scheduling documentation, billing and reporting needs. Plus a lot more in one super easy to use package. Right now, Neta health is offering a special deal for healthy, wealthy, and smart listeners. Complete a demo with the net health team and get $100 towards lunch for your staff. Visit net health.com/ [inaudible] to get started and get access to free resources for PTs like eBooks on demand, webinars, and business tools. Once again, that's net health.com/l I T Z Y my last name very, very easy now onto today's episode. So what we're doing with the podcast this month, and really every month going forward is we're going to have several guests that are all going to talk about one topic in various forums.
This month, our topic is ACL injury and rehabilitation. And my first guest is not only an incredible physical therapist, a great researcher, but also a great friend of mine. That is Dr. Amelia, Aaron Dale, or Amy Arundale. So Amy is a physical therapist and researcher originally from Fairbanks, Alaska. She received her bachelor's degree with honors, from Haverford college, gaining both soccer, playing and coaching experience throughout college. She spent a year as the William Penn fellow and head of women's football at the Chigwell school in London. Amy completed her DPT at Duke university and throughout gained experience working at multiple soccer clubs in the U S and Norway. Amy applied this experience working at balanced physical therapy, providing physical therapy for the capital area soccer club. Now North Carolina FC youth, and the U 23 Carolina rail Hawks. In 2013, Amy moved to Newark Delaware to pursue a PhD under Dr.
Lynn Snyder, Mackler Amy's dissertation examined primary and secondary ACL injury prevention, as well as career link and returned to performance in soccer players. After a short postdoc in Linkoping Sweden in 2017, Amy joined the Brooklyn nets as a physical therapist, the biomechanics as, as the Icahn school of medicine at Mount Sinai health system, as a visiting scientist, currently, Amy is transitioning to a new role as a physical therapist at red bull's athletic performance center in Austria, outside of work, Amy plays Australian rules football for both the New York magpies and us national team. She has also been involved in the AP TA in the AA S P T, which is the American Academy of sports physical therapy, including serving as director of AP TA student assembly, a member of the AP TA's leadership development committee, chair of the AASP membership committee, and currently as a member of the AASP T diversity and inclusion committee.
So what do we talk about today? All about ACL's right. So we talk about injury prevention and risk mitigation programs, how they work, what the pros and cons are how collaboration is so necessary amongst all stakeholders and why exciting new research that includes motor learning principles, creative thinking, and problem solving, and are there gaps in the literature and what can we, as clinicians and as researchers do about those gaps in the research. Now, the other thing Amy has so generously done for our listeners is she is going to give away one copy of basketball, sports medicine in science. This is a book that she was involved in as an editor, and it is over 1000 pages. The book is massive, it's huge. And she's going to give a copy away to one lucky listener. So how do you win that copy? All you have to do is go to my Instagram page. My handle is at Karen Lindsey, and you will find out how to win a copy of basketball, sports, medicine, and science. Again, that's go to my Instagram page at Karen Lindsey, and we will give this book away to one lucky listener at the end of the month of February. So you have the whole month to sign up for this. So a huge thanks to Amy and everyone enjoyed today's episode.
Hey, everybody, welcome back to the podcast. So this month we're going to be examining ACL injuries and ACL rehab. And my first guest this month to help take us through the ACL Mays is Dr. Amy Arundale. So Amy, welcome to the podcast. Thank you so much. We're starting up at the beginning of the year with the A's with it. I didn't even think about that. Yes. But then next month we go right to running and just skip everything else in between. That's fine. Excellent. So Amy, before we get into sort of the meat of the episode, what I would love for you to do is tell the listeners a little bit more about some of your more current research projects, things like that. So I will hand it over to you. Sure. So I'm just finishing
Up as a physical therapist and biomechanics at the Brooklyn nets. So I've been working clinically with them and then doing a little bit of kind of in-house research as well. And then on the side have been working on a few different projects. The biggest one right now is starting the revisions for the knee and ACL injury prevention me Andrew prevention, clinical practice guidelines. So those were originally published in [inaudible] in 2018 and clinical practice guidelines get revised every three years. So 2021 we're due for we're due for a revision. So that's my, the biggest project I've got going right now. And a few other things working with the United States Australian rules, football league on some injury surveillance and injury prevention, particularly on the women's side. And I'm getting ready to move to Austria to begin working for red bull and I, which I'm really excited about that.
Amazing, amazing. They all sound really like really great projects. And since you brought up injury prevention, let's dive into that first. So there are a lot of injury prevention programs. So can you talk a little bit about those programs in general, and then talk about really, what is what's really key for injury prevention in our athletes when it comes to those programs?
Absolutely. So there's a range of different programs that have all been published on and some of them are probably a little better known than others. The FIFA 11 plus, or what's now known as just the 11 plus maybe the, one of the most notable it actually came out of a program that was called the pep program. So the 11 plus was kind of aimed at soccer players, although it has been tested in other athletes and it's considered, it's kind of a dynamic warmup. So it has some dynamic stretching and some running, some strengthening, neuromuscular control, some balance exercises within it. And most of the programs that we see that have been researched are similar kind of dynamic warmups and include a variety of different things that help athletes kind of get warmed up. So some of the other ones that have been published on include the control or knee control program coming out of Sweden at the microburst and the ACL prevention in Norwegian handball has had some great success and great literature.
There's the harmony program and then the sports metrics programs a little bit different. It's actually a program that was designed to be kind of a in and of itself. So it's a three times a week, 90 minute per program, primarily plyometric based. So it's a little bit different from the other programs, but has also been successful. So we've got a number of these programs that we've seen to reduce knee and ACL injuries in particular. And most of them actually have been quite successful at reducing just injuries as a whole. But the key components that we see in particular being important for ACL and knee injuries are that these programs have a strength component. So they're building strength, particularly in the hips, the quads, the hamstrings, but also in the core. So it kind of proximal in like terms of like hip and core strengthening, being important plyometric component seems to be important. To some extent a balance component may be important, although that's kind of questionable as to like how important that is. And that's one of the things that we still need more literature on is how do these components interact and influence each other? Because we seem to know what we think is important, but how much and how those different components interact. We still don't know as much about.
And when we're talking about these programs, I would imagine some of the most difficult aspects of them, especially if we're looking at a younger population. So your high school, even collegiate athletes is doing them. Yup. So can you talk a little bit about implementation and compliance with these programs and how to instill that into these players and teams?
Yeah, I think, you know, we've got, like you said, we've got great information. We know these programs can work, but for them to work, you have to do them. And that implementation piece, you know, whether that be in clinical research you know, we talk about that gap between research and clinical practice. We really see that here in ACL injury prevention. And part of that also is it's not just physios in implementing where we've got a whole range of stakeholders, whether those be the athletes themselves, to coaches who are often running training sessions to parents who really have to kind of be bought in to teams and clubs as a whole. Because if you have a culture that kind of instills the importance of doing a prevention program, then it's going to kind of, it may benefit in kind of trickling down. And that's also a wider culture as well.
Social media scene pro teams do it. There's all sorts of layers to this. But what I think implementation really takes is identifying with that athlete or that team what's what are barriers what's important? What do we feel is, is most important? What's not as an important, and then coming up together kind of, kind of with a collaborative strategy to overcome what are those barriers? So we know information and knowledge kind of that buy-in is important. Why the why, why are we doing this in the first place? But then there's also some of the actual practical pieces of your athlete might not want to do an exercise lying down in the grass because that grass might be wet. They're going to be wet for the rest of their training session, wet and cold for the rest of their training session. So I think it has to be a really collaborative effort.
And each in each situation that solution may look a little bit different. We've got some really kind of interesting information coming out. For example, the 11 plus has now a couple of studies on breaking it apart. So taking some of the pieces, for example, taking the strengthening pieces and putting them at the end of training sessions. So coaches often complained that, you know, these injury prevention programs take too long and when you've only got the field for an hour, they don't want to give up 20 minutes of their training session to do this program. So now let's take, maybe we can take this strength piece out. I means, all right. So maybe it's 10 minutes warming up at the beginning. That's probably a little easier for a coach to swallow. Then as we're cooling down, maybe we're off the pitch where we get everybody together, we finished those strengthening components. So we're still getting the entire prevention program done with that training session, but it's split up. And so thinking creatively like that are some of the ways that I think we can do a lot better in our implementation, rather than just saying, do this, here you go. Why aren't and then coming back and saying, well, why aren't you doing it?
Right, right. Oh, that's, that is really interesting that and what is, does the research show that splitting it up is still as effective?
Yeah. From what we know thus far, it does seem to be as effective. I think there's some other projects that are starting to look at, can you actually do that strengthening piece at home now there's other pieces that, you know, compliance at home, remembering doing those exercises the right way that could come into play there. But as of right now, what it seems like splitting it up does seem, seem to be splitting it up. At least within a training session does seem to be as effective.
Excellent. And so aside from time and constraints on like you said, wet grass, things like that, what are some other common barriers that you have seen or that the research has shown to be a barrier to doing any of these? The above mentioned prevention programs.
Yeah. I think coaching education is a really big one. So whether there's a few studies in Germany that we're just looking at a coach's awareness of the 11 plus and for a program that's kind of sponsored by FIFA, you know, it's promoted as kind of this soccer warmup, you would think that coaches would be kind of aware of it. And it's, it's very quite, it's actually quite surprising how few coaches are, are aware of it. Part of that is it's not in their coaching education. So at least in soccer, as coaches move up, what kind of within the ranks and, and in higher level teams, they've got a complete licenses, just like you have to complete a license to be a physio and complete continuing education in soccer coaches do to getting that program into that coaching education, I think is a really important piece.
But then there's also the piece of helping them understand, again, coming back to that, why, you know, yeah, you want your players to be available. You don't want your players injured. And that's not just a, an immediate fact, but helping them understand the long-term implications, especially of something like an ACL injury, this is not an injury. That's just going to mean you don't have this athlete for a year. This is something that's going to affect how they play long-term it's gonna affect their knee long-term it could affect their career. So this has long-term implications. Buy-In also can come from kind of some of the performance effects, the stronger, faster, more talented athlete that's that there are some of those performance effects coming potentially from performing some of these injury prevention programs or injury prevention or injury risk medic mitigation programs that can help buy in.
And then if we just look at Google would cut straight to the chase, is coaches want to win oftentimes and money. If you've got more players available, we know more players available equals a more successful team. And even Holly silver is actually in some of her dissertation work looked straight at the more you do the 11 plus the more successful the NCAA division one men's team was. So there's, there's she, she actually was able to draw a connection between doing the FIFA 11 plus and winning that those are the types of things that oftentimes coaches will latch onto and say, yeah, I want to win. Or clubs will say, yeah, we want to win. We want to do that thing that makes us that, that next level that makes us better at the higher levels that keeps us earning money.
Okay. Exactly. So from, from what it sounds like is to get these programs implemented is you need a lot of collaboration from everyone, from all the stakeholders, whether it be the coaches, the trainers, the physios, the players, the owners, when we're talking about big league teams and, and with our younger, our younger subset of athletes, parents, coaches, and the kids themselves. And, and I guess communicating the value of these programs depends on who you're talking to, which is why, if you're the physio communicating the program, you really have to have a different set of communication bullet points, if you will, if you will, for each person on the, within that team, because you're going to talk differently to a parent than you are to an owner of a team, or you're going to talk differently to a coach than the player or the parents. So really knowing how to, how to talk to those stakeholders is key. And I think everything you just said will kind of help people understand how to have those different conversations with different people.
Yeah. And I think there's all the other piece that some of those conversations is really empowering them. So there's the education piece and helping them understand, but there's also the empowerment piece that you may be a physio and you may have this injury prevention knowledge, but you don't have to be there for this to happen. It's just as effective for you to run this program as it is for a coach or a parent to run it. And we have, there's some good data on that that coaches can run really effective injury prevention programs. And so helping them kind of take on that role and say, yeah, no, I, I feel confident in taking my players through this. I feel confident in knowing why we're doing this there. I think that's the second piece too, is that it kind of empowerment piece, and maybe it's a player, maybe it's a captain that, that needs that education or that kind of empowerment as well.
I think the generation of players that's growing up now is going to be very different from the generation of players say that you and I played played with we didn't understand or really have much of this. Whereas I think there's some really, there's some kids growing up now who are growing up with some amazing knowledge. And I think also coming with it, hopefully some better strength, some more and more neuromuscular control than maybe we had coming through puberty as well. So I think it's exciting to kind of see where this next generation is going to be, because I think we're going to have some athletes that are just like that more empowered to know more about their body. Maybe have a little bit more control maybe even coming with also potentially better talent who knows, who knows? Yeah. TBD to be determined. So you mentioned a little bit about motor learning. So let's dive into that a little bit because there is new research that includes motor learning, problem solving creative thinking. So what exactly does that mean in relationship to ACL injury?
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Yeah. So I think it's a really exciting area. And I think we're really just kind of tipping a little bit of the iceberg. People are starting to pay attention to some of the work that's coming out. And I think it's, it is really exciting and in the kind of prevention realm what we're seeing is people kind of pointing out that the programs that we have, we know we kind of have some principles of motor learning, but the programs in injury prevention that we have haven't really paid much attention to them. So at a very basic level one of the things that has been talked about from a motor learning perspective for a while now is internal versus external cues. So we know that giving an external cube, giving an output outcome focused, Q2 and athlete is going to help them keep that motion kind of more automatic. They're not going to be thinking about like, I need my hip in line with my knee in line with my toe and foot, my knee. Can't go too far over my shoe laces. I need to sit down.
That's a lot to think about. Yeah. You can't
Play a sport while you're thinking about all those things. Yeah,
Yeah, no, no.
So when that, if that cue is external or is outcome-based suddenly that athlete's much, much more, much better able to pay attention to the soccer ball that's flying past them or getting ready to, to bat.
And can you let's if you wouldn't mind, just so people have a better idea of what an internal versus an external cue is. Can you give an example of, let's say a situation we'll use soccer as the example and give an internal cue and then give an external cue so that people can differentiate.
Yeah. Yeah. So maybe, maybe we'll do say we're doing like a single leg squat, similar to what I, what I just said. So an internal cue might be, I want you to keep your hip, your knee and your foot all in one straight line that external cue might be giving them a we'll say a pole that's lined up in front of them and you might not even tell them what they're, what what's going on. Maybe you've got a pole in front of a mirror, so that's poles running vertically and they're, they're they're we, we just set them up so that their foot's in front of that pole and they're doing that single leg squat. So now you've got a visual line in front of them. You're paying their, their attention is going to be on that visual line. As they're doing that single leg squat, suddenly you see that they see that like, if their hips pretty far adducted or their knees collapsing in, you've got a line you can say, focus on that line. I'm going to focus on that line. Got it. That one, it isn't their body. Other cues, maybe like giving analogies I want you to think of your body as a column or that's, that's not a brilliant one. But you know, things like that. So analogies are helpful for external cues. They're also we'll get in, I'll get into that in a, in a sec, cause they're actually another,
Go get into it, get into it.
So analogies also bring in another piece of motor learning, which is called implicit learning. Again, kind of having that internal picture of what emotion should like should look or what that motion should feel like is implicit learning. So you've got external and internal, external internal cues, but you've also then got kind of implicit learning. So a great example of implicit learning is when you ask, you know, a really athlete to explain what they do on the court or on the pitch. And a lot of times they can't put words to what they do. And that's, that's kind of a good example of maybe implicit learning is they've got, there's no rules set to that learning. There is no order. It's just, I've got this internal knowledge, internal picture internal kind of motor memory of what, what that is. And I just execute that.
I don't think about it. And so with those, all of my attention can stay to the game. I'm not thinking about how I'm moving. I'm just, just, just kind of to the game. So pulling those back to prevention are kind of injury prevention programs have said, here's a video or here's a picture. This is good. This is bad. Or they've given kind of implicit our internal cues. So those internal cues are those, keep your knee, your hip and your foot all in one straight line where we may benefit and where we might be able to bolster. Some of those programs is by adding some of these, these motor learning pieces at the very basic level, adding external cues, maybe adding some analogies or some implicit learning. Another, another way you can facilitate implicit learning is through dual tasking. One of my favorite things reading through some of the literature is in studying implicit learning. A few authors have taken novice novice golfers, and these novice golfers have, have to go and put, and while they're putting they basically yellow letters.
So you literally just be out there like trying to learn to put you, you don't. I know how to put, you may not even get any directions, but you're just out there kind of yelling some letters, because if you have to generate letters, you can't be entirely focused on that pudding. So there's that aspect actually, of having two tasks going on at once. That means not all your attention can be on one of those tasks. How does that help? How does that help the movement? Yeah, so, so that's a very good question. What it means is, as you're learning, it it's like harder, but yeah, once you get to that kind of point where you're comfortable, you're able to execute that movement. It's an automatic movement, it's unconscious, it's automatic. And when we put that in the context of sport, that means that movement is happening without the athlete thinking about it and their attention remains, remains elsewhere. Their attention can remain on the game, that's going on the ball, that's flying at them. You know, that random thing that just flew by them that wasn't the ball and wasn't part of the game, but could be that perturbation, that in another situation could be distracting enough and could lead to an injury situation. Potentially.
Got it, got it. Yeah. Like I, and you and I have had this conversation before, because I have a young athlete and we're doing, trying to do incorporate some of this stuff. So one of the things we're doing is I'm having her do some unpredictability drills with clock yourself, but we're trying to do them in Spanish. So she has to say things in Spanish as she's doing them. So that she's a little do. So she's accomplishing this kind of dual tasking. And, and I will also say it's fun. It's fun for the patients, fun for the therapist. And they kind of understand while they're why they're doing those things. And then every once in a while, just like throw a ball at her and see what happens.
And you put this in the context then of some of those injury prevention programs and coach buy-in. So let's put Bali's in with single leg squats, but, but you know, squats and you jump into a header. There's already a little bit of some of that in some of the programs, but the more we can get that ball, some of those technical skills involved mix them potentially in with some of the movements that we're working on, maybe that might help with some of these, this kind of adding in some of this motor learning piece. Now I say all of this, none of this has been tested yet to change any of these programs we're really doing or to kind of, we need to go back and test them. And so, you know, this is where I say this, but it is kind of hypothetical, but in thinking about it, as well as we're kind of trying to overcome some of those barriers, that 10 minutes, that we're not, maybe we're at 10 to 15 minutes where we're trying to convince a coach to do something.
Coaches are going to buy in a lot more. If there's a, if they can build some skills into that or they can see the sport reflected in it, rather than it just being kind of this abstract quote unquote injury prevention program. So can we get some of this dual tasking, can we get some of this kind of real world kind of environment type demands and challenges integrated in with some of those pieces that we're trying to build from a neuromuscular standpoint, can we mix them all together and end up with a maybe potentially more beneficial outcome?
Yeah. And, you know, as you're saying all of this, it's kind of opening my mind up into these programs as being these living, breathing programs that aren't set in stone and that have the ability to change and morph over time as research continues to evolve. And I think that's really exciting for these programs as well, because you don't want to have these programs be thought of as stale because then that's going to not help with your buy-in.
Yep. Yeah. And that's one of the complaints that you sometimes see about some of these programs is all right, so my team's done him for a season. They've all mastered, you know, all my players have mastered this program. They're bored of it now. And the likelihood that every single one of your players has mastered every single one of those exercises is that we'll put that into question, but we'll put that one on the side, but yeah, if you're doing the exact same program, the exact same exercise, every single training session for multiple years, yeah. Your players are going to get bored of it. And so are these, some of the opportunities where we kind of help with that buy in where we make it a little bit more creative, where we help kind of with some of those implementation pieces to make it more interesting to make it more long-term and to, to really help with people wanting to do them.
I think it's great. And now we're, we've spoken a little bit about research here and there. So let's talk about any gaps in the research. So, I mean, are there gaps in the research? I feel like, of course, but are these gaps something that can't be overcome?
No. All of the gaps that at least dive I'm aware of, and I'm sure there are more I just finished writing a paper alongside Holly and grant the Mark. So Holly silvers and, and Gretta microburst for the journal of orthopedic research. And, and one of the things that we did was kind of go through the literature and identify some of the gaps.
What were, what were they, you don't have to say all of them, just give a couple of a couple of the big ones,
But one of the big ones is a lot of our literature is focused on women, which is important, but in total numbers, we still have more ACL's happening in men. So we need more research in men. A lot of our research is in soccer and handball. There's a lot of other high-risk sports at there. So there were focused kind of on team sports but there is some pretty high risk team sports, something like net ball play ball volleyball have very high ACL injury numbers, individual sports things like gymnastics and wrestling. And those are also Tufts sports to come back to they're very high impact or they're very MBA. They've got some crazy positions that you don't see. So individual sports, I think have quite lacked outside of skiing. Skiing's got a lot of attention. One of the biggest ones that I think for me is really important is we don't have good reporting of the subjects and the diversity within the research that we've done.
So most of the, the research that's been done has been done in the U S some in Canada and in Scandinavia, or at least in Europe as a whole, there's been a few studies that have been in in Africa. But we even within the studies that we have in the us and Europe and Australia, we don't, none of them have reported any of the, like really the, the, the race or ethnicity of the athletes who were part of them. So those may have implications and Tracy Blake did a amazing BJSM blog that was kind of a call to action for researchers. And it's one that I'd love to echo here that we need to be better at reporting our biases looking at our, our subject populations and funding and encouraging studies outside of kind of we'll call it quote, unquote, the global North. I think that's, that's a big gap that we need to fill and we need to be more aware of.
Excellent. And on that note, we are going to wrap things up, but what I would like you to do is number one, is there anything that we didn't cover or anything more that you want to add to any of the subjects we covered?
Ooh, I know you always ask this question and I always have never prepared for it.
Well, you know, cause I don't want to like skirt over something and then the guests at the end is like, I really wanted to say this. And she just ended the interview.
Think of it probably right before I go to bed. Probably.
I can't think of anything right now. Okay.
Excellent. Excellent. For any readers who haven't read Dr. Tracy Blake's BJSM post definitely go check it out. We'll put the link in.
Yeah. Yeah. We'll put the link into the show notes here. So you can read her blog app over at BJSM and I agree. It was it was very well written and it was a really nice call to action and or call to awareness. Yes. Yeah, yeah. Right. Maybe not call to action, but certainly a call to awareness, which is step one in the sequence of actionable moves. Definitely. So yes, she's a gym. So now before we wrap things up I'll ask the same question to you that I asked to everyone and knowing where you are now in your life and in your career, what advice would you give to yourself as a new grad? Let's say like not new grad PhD grad, but new
Duke grad, new, new grad coming out of Duke PT school. I'm trying to think of what I said the last time I was on.
Well, don't say it again. No, I'm just kidding.
Well, yeah, that's what I'm worried about saying the same thing again. I think what I said last time, but what is my like big thing is being more gentle on myself. When I came out of PT school, I started work. I was the first new hire new grad that they'd hired. And so I was working alongside some just phenomenal clinicians, but they had the least experience, one head, like 15 years of experience. And I came out of school, unexpected myself to kind of treat and operate on the, kind of the same experience level that they did. And I it's just not possible. So I've spent a lot of time kind of beating myself up. And so it takes a lot of reminding even now that like, I still have, you know, I've graduated in 2011. So I'm coming up on 11 years of experience and it's still not a lot in a lot of ways. So being gentle on myself that I don't have to come up with, you know, everything on the spot that I don't don't necessarily have the experience to know or have seen everything or every course or development. And so being okay with that and being gentle and allowing myself to be, to, to just be where I'm at is, is I think
It's wonderful advice. And just think if you thought you did know everything, I mean, how boring number one and number two, you'd never move on for sure.
Yeah. Yeah. Right. So
You're stuck. You'd be pretty stuck. So giving yourself the space and the kindness to say, Hey, I don't know everything. So I'm going to make it a point to learn more is just good therapy. It's just being a good PT, being a good physio, you know, otherwise you're just stuck in 2011. I mean
Gotcha. Yeah. 11 wasn't bad, but I'm glad I'm not stuck there.
Yeah. I mean, what a bore, right. You'd be like so boring as a PT cause you would never advance.
Yeah. So your ex
Excellent advice. And now where can people find you on social media and elsewhere?
So I am on Twitter at, at soccer, PT 11 I'm on Instagram at squeaky Edgar. I will note that's actually more personal but follow me anywhere cause you'll get some great, great adventures. And those are my primaries social media.
Excellent. And before we hop off, can you talk quickly about basketball, sports, medicine
Science? Oh yeah. I forgot to talk about that in my projects.
Yeah. Let's talk about this quickly. Yes. So
Was honored to be a part of an editorial group that just completed. I just got a book out. It's an ASCA public, a publication on basketball, sports medicine and rehabilitation. So it's a quite the book. But I say that because it is over over 1100 pages if I remember correctly. So it's, it's a, it's a, it's a chunk of a book. But we are, I've got an extra copy of it. So one of our allowed visitors really be getting a copy. Okay.
Well Amy, thank you so much for coming on. I really appreciate your time.
Thank you so much for having me. It's always fun.
Everyone else. Thank you for listening. Have a great couple, have a great week and stay healthy, wealthy and smart.
A big thank you to Dr. Amy Erindale for coming on the podcast today. And of course a big thank you to net health. Again, they have created net health for private, for net health therapy for private practice, which is a cloud-based all in one EMR solution for managing your practice. One piece of software that handles scheduling documentation, billing reporting needs. Plus a lot more. If you want to check it out, there's a special deal for healthy, wealthy and smart listeners. Complete a demo with the net health team and get a hundred dollars toward lunch for your staff. Visit net health.com/glitzy to get started again. That's net health.com/l I T Z.
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528: Dr. Ellie Somers: Bone Stress Injury & Rehab in Female Runners 0
In this episode, Owner of Sisu Performance and Physical Therapy, Dr. Ellie Somers, talks about bone stress injuries, specifically in female runners.
Today, Ellie tells us about differentiating between the male and female runner, and she elaborates on a subjective and objective exam of a bone stress injury. We learn about the most vulnerable sites for a bone stress injury, the misconception about the severity of the diagnosis, and the strategies Ellie uses to get women on to strength and flexibility training programs.
Ellie talks about the concerns that many people have after a BSI, and she gives her younger self some valuable advice, all on today's episode of The Healthy, Wealthy & Smart Podcast.
"Female runners have a lot of particular and special needs and considerations when talking about evaluation from a physical therapist perspective, as well as from a communication standpoint, that need to be considered."
"When you're getting someone into your clinic, you don't want to make assumptions about their circumstance."
Things to consider in a subjective exam for a bone stress injury:
Is the patient grasping why they got into this situation? A bone stress injury isn't necessary about the shape of their body or foot, it's a result of limitations of their dietary intake.
Their menstrual cycle. This can be an uncomfortable conversation for many clinicians, but it is a required question for a subjective exam.
"If a runner is coming to you explaining that they think they sustained a BSI because of their pronated foot or because they were wearing the wrong shoes, we've missed a huge piece of why bone stress injuries actually happen."
The most vulnerable sites for a BSI: The femoral neck, the first and second metatarsal, and the anterior tibia, among others.
The objective exam:
Palpation, single-leg balance, and walking.
More explosive movements. These include the single-leg hops and taking steps up or down.
"You can still be stressing bone and it's going to heal. When we don't stress bone enough, it could theoretically take longer and put that bone in a more vulnerable position."
"Women athletes are more prone to lower bone density than male athletes are."
"Runners kind of have this misconception that running itself actually strengthens bone. In reality, it doesn't really strengthen bone as much as we'd like to think."
"History of bone stress injury is the number one risk factor for new bone stress injury."
"There's no rush. You have your entire life ahead of you to work and refine. As long as you're working on something, you're working towards it."
Running Injuries, Rehabilitation, Therapy, Physiotherapy, PT, Training, Injuries, Sport, Wellness, Health, Recovery, Female Runners, BSI, Bone Stress Injury, RTS
More about Dr. Ellie Somers
Dr. Ellie Somers is a physical therapist, run coach, weightlifting coach and the owner of Sisu (pronounced see-su) Performance and Physical Therapy in Seattle, WA. She also serves as the team physical therapist for the women's United States Australian Rules Football Team. As a private practice owner and coach, Ellie specializes in work with women athletes, specifically runners and field athletes.
To learn more, follow Ellie at:
Email: ellie@sisuwolf.com
Facebook: Sisu Performance PT
Instagram: @thesisuwolf
Twitter: @drelliesomers
YouTube: Sisu Sports Performance and Physical Therapy
Website: https://sisuwolf.com/resources/e-books/return-to-run (FREE gift!)
Hey, Ellie, welcome to the podcast. I'm happy to have you on. Thanks for having me, Karen. So this month we're talking all about running injuries. Just so people coming onto the podcast is the first time you're listening this year, sort of changing up the format each month is a different we're focusing on a different topic. So last month was all about ACL injuries. This month, we're going to concentrate on running injuries, which is why Dr. Lee summers is here. And today we're going to be talking about the female runner. So Ellie, my first question is, are female runners, just little petite male runners, and it should be treated as such.
Well, obviously the answer to that question is drum roll, please. No, yeah, yeah. I think female runners have a lot of particular and special needs and considerations when talking about evaluation from a physical therapist perspective, as well as from a communication standpoint that need to be considered.
And what kind of, can you kind of differentiate that male runner from the female runner? What are kind of some of the big differences that if you are a physical therapist, a run coach, even a personal trainer, a strength and conditioning coach, what are some things that we need to be aware of in the female runner?
You know, the way that I think about this, I actually think about it from a bio-psycho-social perspective. So what women are exposed to in our environments, in our engagement with other human beings, with social dynamics and things of that nature is very different than what men are typically exposed to. I also think of it as you know, generally speaking in terms of adaptability, women and men have the same traits and characteristics, but certainly things that need to be taken into consideration for women include our biology and physiology more specifically our menstrual cycle and hormone cycle. So I tend to think of it as a very holistic thing. And what are the things that female runners might be exposed to that set the stage for certain types of injuries or pain experiences that maybe male athletes aren't or are less likely to be
Right. Got it. And so now let's take a common injury that you may see in a female runner, and let's talk about what you would how you would go about your subjective exam, and then we'll get into objective exam and some possible treatment options, but let's take a bone stress injury, pretty common in female runners. So first talk about, well, actually, let's talk about why is that common in female runners?
That is a great question. Lots of there's probably a lot of nuance to answering that question. I think theories abound and I'm thinking of those series. I think that the primary thing that we get exposed to as female athletes is how do I want to phrase this considerations about our body and in the run community? I think it's a lot more pervasive for women athletes. So not only are women on the whole exposed to messages about their body, that they need to be smaller, that they need to be thinner in the run community itself. Women are then also exposed to this concept that you'd need to be in order to get faster. You need to be thinner. And that sets the stage for eating disorders and diet restriction and limitation that can lead to bone stress injury.
Got it. Okay. So obviously very sensitive subjects. So the subjective exam becomes all the more important. So walk us through maybe how some questions that you would ask and kind of how you would asking keeping that sensitivity of this may be a person that's experiencing maybe some eating disorders or experiencing some body image body image issues. So walk us through your subjective exam.
Yeah. So I think it depends on what they're coming to you for and what you know already. So depending on your clinical setting, you might already know they're coming to see me for a bone stress injury. And this person may have already seen a physician and had the imaging done at which point you may not need to dive into a lot of detail there, but I think what you want to try and capture is is this person grasping why they got into this situation. And I think as a clinical provider, that's working to reduce risk, prevent air quotes around prevent these types of injuries. You need to understand that this person knows that bone stress injury isn't necessarily a result of the shape of their body or the shape of their foot. It's the result of really limitations on their dietary intake. So when you're getting somebody into your clinic, you don't want to make assumptions about their circumstance, but I think it, it behooves you to start to ask questions around, you know, do they understand why they got this injury?
And if their answer to you is while I was over-training, you might want to start to dig deeper and figure out if you can fill any gaps and holes there to help them understand that fueling strategies are a big contributor to these injuries. So subjectively there's that piece to cover. Then I think you also have to think about how do I want to say this their menstrual cycle basically. And I think for a lot of clinicians, these topics can be very uncomfortable, hard to, to talk about, hard to ask questions of, but when you're doing a subjective exam, this is a required question to be asking, what is your menstrual cycle? Like, are you having regular and normal periods? When did you start your period? At what age, if you're not comfortable asking these questions in a face-to-face manner, or you don't think it's appropriate for you, then they definitely need to be included on your intake forms. And you need to be reviewing your intake forms before you see that person in your clinic. So those would be, I think the two primary things that you need to sort of start to get a picture of, because if a runner is coming to you, explaining that they think they sustained a BSI bone stress injury because of their pronated foot or because they were wearing the wrong shoes, we've missed a huge piece of why bone stress injuries actually happen.
And I really do like including that on your intake paperwork, because then even if, whether you're uncomfortable asking that question or not, or you are comfortable either way, I mean, either way, quite frankly, you should be comfortable asking that question. I don't care who you are. You're a physical therapist, you're a healthcare provider. That's a question you should be very comfortable asking because it is part of their medical record. And part of, of like can be part of the reasoning behind these bone stress injuries. But it also gives you if it's on your intake form, it also gives you more information so that when you are in your subjective exam, you can perhaps hone into that and you can even say, Hey, listen, on my on the intake form, I noticed that you're not having like regular periods. Can you tell me a little bit more about that and that's it.
Yeah, exactly. Yeah. And I think all it will show you is, is this person having energy demand issues? You know, we know that if you've lost your period or you're having irregular periods, it can be a very clear objective indication that your energy in is not matching your energy out. And it's what we would call somebody suffering from low energy availability or in the, the more maybe more like broad terminology would be relative energy deficiency in sport. And this can cause a host of different and problems. And the last thing you want to do as a clinician or provider is I think miss that, especially in a female runner, because it just sets them up for recurring bone stress injuries, or recurring injuries. And that cycle will just repeat itself.
Yeah. Now, okay. So you've asked those questions. Are you asking questions on how much are you running? How often are you running? Have you picked up your mileage and things like that? Is that something that you're asking as well?
100%, because a lot of the times people who are training for a new distance of an event, right? So if I have a person who's like I was training for my first marathon, they might have sustained a bone stress injury as a result of some of that increase in strength in training while also maybe not matching that with their fueling. So it helps you get a picture of what this person is training for and why they're training for it and how much training they have. And then you can move forward from there with a more practical plan as a physical therapist on how we're going to strategize a graded return to activity.
Got it. Okay. Any, what else are you asking? What else do you need to know from this patient,
Everything else that you would need to know in a physical therapy exam? I think you know, I think for a lot of folks, these injuries are scary and they've disrupted their lives to a great degree. A lot of these runners will have to stop running for months of time. So all of the same questions you would ask, but then I would also add onto that. You want to know, sometimes you want to know, does this person have a registered dietician as part of their care team? Are they working with an endocrinologist? Have they had any blood work done to determine if they were suffering from relative energy deficiency in sport? Do they have a team of people that can help support their progression back to play? Now? I want to be clear. I don't think every single person who has a bone stress injuries requires a team of people. I think it's an ideal. And if I've got somebody who's come in, who's got a bone stress injury, and doesn't have a team of people I'm planting seeds to get them, that team. So that they're set up for success.
Yeah, that makes sense. Yeah. And gosh, I just had a question and it was like in my head and just went it'll it'll come back. It'll anyway, it'll come back to me. I'll edit this part out. It'll come back to me. Cause it was a good one. It's there it's there. I just there's days. It's just it's. I was like, Oh, I got to ask this question anyway. If I think of it later, I'll ask it later and we'll just splice it in. No one will know the difference. Oh yes. Got it. It's back. Okay. So is there a difference when someone is coming to you via direct access, just versus someone has already been to a physician, they have been diagnosed with a bone stress injury. Let's say they had some imaging done. It has shown up where, what is the difference there? Is there a difference in your examination of this person?
Yes, absolutely. Because, and I work primarily in a direct access capacity. So by when people come to me, they haven't typically seen anybody else. And now it's my responsibility to be able to pick up on these things and tell someone, you know, I need you to go see your physician. We need to rule out bone stress injury before we move forward. So from a purely exam standpoint, when somebody is coming to me, who is a runner who potentially has pain at a site that could be risk for bone stress injury, I need to have the evaluation skills to be able to, to rule that in or rule that out to some degree so that we can move them in the right.
Got it. And what are those sites? What are the most vulnerable sites for a bone stress injury?
Well, the femoral neck is one of the most vulnerable, I would say anyone who's coming in, who's a female athlete. Who's complaining of anterior hip pain. That's maybe a little bit vague and is presenting with some of those additional sort of risk factors changes in their menstrual cycle, low energy availability training, abrupt training changes. I'm starting to stew a little bit and get a little bit concerned. So that's going to be a high-risk stress fracture site, some other high risk stress fracture sites include the first and second metatarsal. And I want to say the anterior tibia as well. It's likely that I'm forgetting one, but yeah, some of those regions are considered high risk. High risk essentially means that the likelihood for healing is a little bit harder, I guess you could say.
Okay. All right. Thank you. All right. Now let's move on to your objective exam. So what kind of things are you looking for? Are you going to say to this person, let's get you on the treadmill and see what you're doing with your run? Okay.
That's the great part of the subjective exam because the subjective exam is going to lead me into thinking whether or not I need to test for bone stress injury before we pursue running. Right. And there are a couple of things that are going to lead you that some of which I've already talked about, but site-specific pain is definitely one of them, localized pain. Sometimes people will point directly to their pain and be like, it's right here. They can have pain in, I know femoral, neck stress fractures. They can have pain with offloading. So sometimes they'll say, you know, like stepping off of a step, I suddenly have pain in my hip. So there are things that you'll just pick up on and then you do not want to get on the treadmill at that point, if you're suspecting bone stress injury, you need to do the tests to sort of rule it out before you get to the treadmill. Some of those tests that I would do, I think first would probably be about palpation. So depending on the area, you know, the femoral neck is
D that's tricky. That's a tricky one to help paint,
Be able to get there with your hands, but certainly a medial tibial region or an anterior tibial region. You can palpate that with your hands. And we're looking for pretty pinpoint tenderness. From there we might get them up and then first have them walk. What's their walking look like, is there any offloading happening then I might have them do a little single leg balance. How does that feel? A lot of the times people may not have very distinct acute pain with some of these low level impact activities, right? So if they're presenting with no pain, now this sort of, I'm going to describe it as like this first level, no pain with walking, no pain with single leg balance. Now I want to get them doing a little bit of an explosive move, maybe a step up or step down and determine are they having pain with some more functional tasks? And I think the single leg hop test is a pretty, like just straight up and down. Three hops is a pretty decent maneuver for almost any lower extremity potential stress fracture site. You know, I don't know the statistics on reliability and validity, but it's one that I use very regularly with somebody I'm suspecting that. And then from there you can kind of make a determination about how you want to proceed. Typically, speaking of the folks that I work with, they're going to have pain in one of those moves.
Yeah. And, and at that point, does it then come down to, if you're seeing them via direct access, explaining to them, Hey, listen, this is my hypothesis. Let's get you to a physician at that point. Yes.
Yeah, yeah. Okay. Yeah. Usually I'm revealing at that point, I'm concerned for bone stress injury. I want to get you, you know, examined for that. So, and they can, you know, go to their physician that they know and that they trust. But I think it's important depending on the region that we get the right imaging. Certainly if I hip femoral, neck stress fractures suspected, I really want to push that person to try and push for an MRI. So you know, it kind of depends on your relationship with the person and where they're at on a lot of different levels, but, but that's what we're going to be going for.
Okay. And so let's say this is someone who has already gone to the physician. They've had the MRI, this is diagnosed. So you've done your evaluation now, what do you do? I guess the question is, is, are they come, are they non-weightbearing at this point? What are, what are some things that we can do as physical therapists for these patients when they're coming in? They've already been diagnosed?
Yeah. Well, so many of these athletes don't get referred to physical therapy in the first place, which I think is a problem. But yeah, if you are getting these people, we really do want to be loading those tissues. And bone responds really positively to stress as long as the environment is you know, a strong, healthy, robust environment as well. So depending on their level, we're going to be progressively loading those tissues all the way up into the point where they're cleared for a return to run. So, you know, squats step up step downs. If they're not cleared to weight bear, you know, we're definitely doing stuff on the table, that's just pull it using the muscles around that tissue. And even just by using the muscles around that tissue and the injury, you're stimulating bone adaptations that are positive.
And so I guess the, the thing that might come into a patient or a therapist is, well, if I'm non-weightbearing, I don't really want to do anything with this side. Cause what if I make it worse? Right. So is it, is this injury, let's say we're talking about a femoral neck BSI, is this injury so fragile that if you're doing things in a non-weight bearing capacity, can that make it worse?
Not typically. You know, I, I, I tend to think that people who have had BSI or are so much more resilient than they get credit for, I have had and seen, and I don't commend this necessarily. So many runners who have run through BSI and there is, there is some toxicity there to unpack that we don't need to do today, of course. But all that tells me is that you can still be stressing bone and it's going to heal. And I think what we know is that when we don't stress bone enough, it could theoretically take longer and put that bone in a more position. So in my opinion, all of these athletes with BSI need to go to a physical therapist so that they can load those tissues up. Yeah,
No, that makes, that makes perfect sense. And I just wanted to kind of make that distinction because I'm sure if someone is told, Oh, you have a bone stress injury, you know, scary, scary, right. Very scary. And that's where I think the team comes in. Like you said, assembling this team around that, around that runner is so powerful,
Right? I mean, gosh, I think those soft skills are invaluable when working with women who have had BSI, because so many of these runners it's like totally ruined their perception of who they are and their worth and their value. And so you have to be really good at being a kind and generous and thoughtful and considerate to that person's experience because it's still very much in a way I'm going to use the word trauma to them. And I think not everyone is going to be ready to work with a mental health therapist or work with a registered sport dietician. But I think as their support person, your job as a physical therapist is to really listen to what's going on and gain some of that trust so that you can softly nudge them in those directions and work them towards a more robust, healthy lifestyle.
Yeah. Because you don't want this single bone stress injury to set off a cascade of other events. That could be really detrimental to them. Not only as an athlete, but just as a person.
Right? Yeah. I mean, women athletes are more prone to lower bone density than male athletes are. I'm just women in general. Let's just use women in general and runners, you know, runners kind of have this misconception that running itself actually strengthens bone in reality. It doesn't really strengthen bone as much as we'd like to think. And all that means as women is we need to be thinking about other ways to strengthen our bones. If that's something we care about.
Right. And that's where a good strength training program comes in for runners because I have spoken and I have treated plenty of runners and runners like to run when you tell them, Hey, you, we should get you on a robust strengthening program. It's like, what a no. So, yeah. So now let's say you're, we're still in the treatment process. So we're, we're past the, this vulnerable part of the bone stress injury. They're able to weight bear, they're able to do more. What strategies do you use to get these women on to strength, training, flexibility programs?
Honestly I show them, I think that's like a big component of how I work with the people that come to see me is showing them what they need to be doing. And first of all, that it's fun and that it can be fun that it's not intimidating and that we can keep it really simple and easy. And it doesn't have to be a huge long laundry list of exercises to keep them healthy. And FEMA women especially are so subject to carrying, you know, a list of 20 to 30 exercises that they're doing to, you know, through the guise of staying, I'm going to use air quotes, healthy and keeping tissues healthy, and it's just way more than it's necessary. So I think part of why women, like working with me is I have been able to really speak their language, pare things down significantly. So that it's simple. It's, you know, 25 to 30 minutes, one, one to three times a week is really all runners need to, to keep that bar trending in the positive direction.
Yeah. And I think that's an important distinction to make because oftentimes we think we have to work out five days a week and it has to be this like really complicated. I have to do a chest day. I have to do a leg day. I have to do a hamstring day. I have to do a quad day. I have to. And with all of that said, you're like, Oh, screw it. This is too complicated. I'm just going to run. Yeah, no,
I do not blame them whatsoever for giving up on programs in part, because they're just so complicated. And for runners, we just need to keep it simple, keep it clean, keep it short and sweet and to the point and get on, get on our way.
Yeah. Excellent. Excellent advice. Now, is there anything that we missed as far as that treatment aspect with these women with bone stress injuries, and obviously we're not going into like individual programming for an individual person because it's so varied. I'm sure. But I guess, are there X speaking of exercises, are there exercises that you do like to include with most of your runners?
Yes. So they're getting lower extremity strengthening exercises. So, you know, a squat and a deadlift of some sort, all of my runners will give that we're also going to be incorporating and especially for bone stress, injury, plyometric, explosive exercise. So, you know, squat jumps, counter movement jumps, broad jumps, Pogo jumps. We don't have to do those in like a hit style. If that makes sense. We don't need to be like every minute on the minute you're doing this many jumps or whatever for runners, what we need to be doing is doing it to load the bones for one and two, doing it to create and foster tendon stiffness. And so I think there's a little bit of a misnomer amongst women athletes, especially that in doing plyometrics, they have to be really, really intense. And I'm of the opinion that we want your running to be really, really intense. We don't also need your strength training and your physical therapy to be to the nth degree, intense just needs to be targeted.
Yeah. That makes a lot of sense. So you don't need to like kill yourself on your workout day and then go out and run the next day with like jelly legs. Right.
Yeah. It doesn't make sense. It doesn't make sense from a running standpoint. It may make sense in, in another population. Yes. But you have to be specific with your population. And this is where the skill of a good physical therapist comes in to be able to tailor that program, to that specific runner and what their needs are, especially coming off of a bone stress injury. Right. Exactly. And is there a fear in the runner after a bone stress injury, and you say to them, let's start doing some jump squats. Like what lady are you kidding me? Yeah.
Yeah. I think people are pretty forward with some of their concerns and their worries. And depending on the capacity that you're seeing them, you see it in their body language. Right. But that's why physical therapy is so advantageous because that's where we Excel is helping people understand why something is valuable and then why it's safe. So I think it's about addressing those fears, head on getting at the heart of what they're concerned about and meeting them exactly where they're at. You know, maybe if they're not ready for that, we just try something else. In the meantime, until they're building up confidence, there's not a single person that I've worked with who has had a bone stress injury that doesn't have some of those fears pop up. It is a very real piece of a return to sport on any level. So,
Yeah. Agreed. Excellent. Now, is there, is there anything that we missed, anything that we glossed over that you feel like you want to explain to the listeners a little bit more, or do you think we've covered, you know, sort of the high level basics on how you would look at one of these patients with a bone stress injury?
Yeah, I think we covered most of it. You know, I think in, you know, reflecting back, it's really just understanding that we don't want to make assumptions about somebody's circumstance. You don't want to assume that somebody with bone stress injury has an eating disorder. I've worked with a number of people who have bone stress injuries, who do not have what I would consider disordered eating to the level that it's clinical. They just didn't understand how much fueling might be required for their activity. So I think in your subjective and in your relationship building with these people, it's important to keep that in mind that we don't need to medicalize everyone that walks in our door with a bone stress injury, but certainly we want to prepare them better for the future. I should also add that history of bone stress injury having had one in the past is the number one risk factor for a new bone stress injury. So in your history, in your subjective exam, that's another great question to ask. Have you ever had a bone stress injury before? If the answer is yes, you're already starting to postulate that that could be a possibility.
Got it. Excellent. Excellent. Well, this was great, Ellie. I think that you gave the listeners a really, really robust understanding of looking at bone stress injuries from the point of view of a physical therapist. So thank you very much. This was great. Thank you. Yeah, I appreciate being here. Of course. And then where can people find you?
Yes. So you can find me on my website, www.cc wolf.com. It's brand new. I'm just going to say brand new France shine. You can also find me on Instagram handle of@theccwolf.com. And if you want to reach out to me personally, I love getting emails from folks it's Ellie, E L L I E at [inaudible] dot com.
Awesome. Well, thank you so much. I have one final question for you and it's one that I ask everyone. And that's knowing where you are now in your career and your life. What advice would you give to your younger self? Let's say right out of PT school.
There's no rush. There's no rush. I think, you know, as a young PT, it was like, I want to be the best now. And you have your entire life ahead of you to work and refine and you know, as long as you're working on something, you're working towards it. So there's no
Excellent advice. I love that. So everyone, no rush, no rush to all those student physical therapists out there. Well, Ellie, thank you so much. This was great. I really appreciate your time. Thanks Karen and everyone. Thanks so much for listening. Have a great week and stay healthy, wealthy and smart.
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