HAE series: the Pulmonary system

The Basics

While the heart may seem like the most important organ in your body, it would be quite lonely without the pulmonary system to which it is attached. The pulmonary system is responsible for the critical task of gas exchange - or the transfer of fresh oxygen into the bloodstream, and the removal of carbon dioxide from it. Oxygen makes all the things happen. WIthout oxygen, there would be no energy. Without energy, there would be no functioning tissues, organs or muscles. In fact, the brain can only function about three minutes without oxygen and if cut off for any longer, will likely sustain some degree of brain death (*except in cases of severe hypothermia, but that’s a story for a different time.) All said and done, you inhale and exhale approximately 2000 times a day, exchanging 11,000 Liters of air by the time you start the next. 

This process occurs in four different stages. Pulmonary Ventilation initiates the cycle by drawing air into and forcing air out of the lungs. The muscle that forms the base below your lungs, the diaphragm, contracts and relaxes to create a vacuum effect; the oxygen rich air from the atmosphere is drawn in through the nose and mouth, and into your system by way of a series of pipes. The air first enters the pharynx, then passes into the larynx. The larynx becomes the trachea and the trachea splits into the two primary bronchi, which then each split into secondary bronchi, each of those then splitting into more and more segmental bronchi. This elaborate splitting and resplitting creates the tree-like shape that makes up each lung. The right lung is broken into three lobes; the upper lobe, the middle lobe and the lower lobe. The left lung only gets two, because it leaves a notch open where the heart sits and has an upper and lower lobe only. Each of the very last bronchioles in the tree ends at an alveolus. Multiple alveoli bunch together to form an alveolar sac. This is where the action happens. 

The alveolar sacs are responsible for the External Respiratory phase. Each sac looks like a tiny cluster of grapes and this is where the lung tissue connects to the blood stream. Blood leaves the right side of the heart by way of the pulmonary arteries and ends as capillaries who wrap around the alveolar sacs where they can proceed to transfer their gasses. (If you’re quick on the pick up, you’ll realize this is totally counter intuitive as arteries are usually associated with red, oxygen rich blood, but the term artery actually just indicates direction. An artery is simply a blood vessel which goes away from the heart, which in this case, it does.) During this gas exchange, carbon dioxide is deposited back to the lungs to be exhaled, and oxygen is transferred from the alveoli into capillaries to bind to hemoglobin and enter the blood stream. This, now oxygen-rich, blood travels along the pulmonary vein into the left side of the heart to be pumped out into the body. (Get the counterintuitive reference now? Though veins are usually oxygen-poor, these are oxygen-full because a vein simply indicates it is returning to the heart.)

The role of the elaborate vascular system is now to enable the Transit of Respiratory Gases. Blood travels throughout the body through arteries to every single muscle, tissue and organ in your body and provides the oxygen needed to created energy to keep those cells functioning. As these arteries turn into smaller capillaries and terminate at their designated tissue site, the fourth and final phase, the Internal Respiration completes the cycle. Oxygen transfers from the bloodstream into the tissues, and the tissues trade out the residual carbon dioxide that has been left there as a byproduct from energy production. I’ll leave you with a fun fact: Once that carbon dioxide is exhaled back into the air, it is used by plants for photosynthesis  - which then creates more oxygen for us to breathe. #CycleOfLife.

You can watch a pretty sweet Nat Geo video about the lungs here.

Core Values

I attended a webinar last night the speaker asked us to identify our core values. What I found particularly interesting, is she specified that our core values should be both relevant to our personal lives and our business practices, because contrary to popular belief that you should keep your professional and personal life separate, a business can be most successful and fulfilling when these values align. As an independent practitioner, I found this concept resonated with me longer, as one of the things I value most so far about running my own practice is that I get to do things MY way. While I started HAE/PT simply as a way to be able to continue to work while meeting the unusual demands I now face at home due to the pandemic, it has transformed into something else entirely. It has given me an opportunity to to use my skills and experience in the best way I know how to help my patients in more meaningful ways. In thinking about it in this light, of course my personal core values should line up with my professional ones, and I can see how making these a regular part of the way I do my business will be the best path to success.

The core values, and the values I strive to live my life by and design my business around, are Strength, Support and Stability.

Strength:

I’ve always found myself striving to be strong. As a person, in my athletic pursuits as a swimmer and as a physical therapy clinician. Strength fosters resilience. When life becomes challenging, physically or emotionally, it is your strength that helps you remain resolute, that helps you achieve your goals and remain whole when you emerge on the other side. This is a value I work on daily in myself. It is an attribute I work on at each visit with my patients. And it is a value I wish for as I develop my business.

Support:

I’ve been in the ‘helping’ field as long as I can remember. My first job was a mother’s helper when I was somewhere around nine or ten. I started volunteering at eleven as a swim teacher for kids with disabilities. I continued in this role until I left for college. I worked at various camps and recreation programs for people with disabilities from my teens into my early twenties and when it came time to choose a career, it felt like a given to make a choice within the helping professions. There certainly weren’t any other careers that piqued my interest, and the only jobs that felt worthwhile to pursue were ones that would allow me to support other people. I strive to support my friends and family when they struggle, and I feel like being able to support my patients as they recover from illness and injuries is best part of my job. In opening my own practice, I have given myself the flexibility to expand the ways I support my patients. I have developed programing to support patients before, during and after physical recoveries and under a greater umbrella of health and wellness, and can now provide support during my visits without the constrains of productivity standards and other factors that limit how I choose to spend my time.

Stability:

Stability is successful maintenance of balance. Stability has far reaching implications in all areas of health - mental, physical, emotional and spiritual. While some people yearn for freedom, flexibility, or adventure, and while I also value all of those things, I believe that you can only truly grow when you have a stable base to keep you grounded. I’ve always been drawn to images of trees with giant sprawling roots, and wear a necklace each day with that depicts a tree of life, embellished with my children’s initials. I feel most at peace in the woods, among tall trees, in fresh air, on a clear fall day. While I can’t completely put into words how why I feel this way, I can tell you how it makes me feel. It makes me feel calm. It makes me feel like I can see the ‘forest for the trees’ - it helps me put my problems in perspective and see my world on a larger scale. When I’m stressed, or overwhelmed, I can take a walk in the woods and emerge feeling renewed and optimistic. While I don’t consider myself spiritual, per say, there is a passage that always catches my eye during the high holidays each year. Paraphrased, it reads:

“Will you be troubled every passing wind or be the calm within the storm?”

I strive to live my life as the calm within the storm - and want the very same for my patients. I want for them to experience stability in their health by providing them with an education beyond what a physical typical therapist may provide. I want them to be stable, literally, so they can avoid falls and remain free from injury. I want to be able to support each of them, to help them develop the strength and the stability they need to age successfully. I believe these values, my core values, are what makes HAE/PT special and I look forward to sharing them with you.

STRESS!!! Three Easy Changes You Can Make Today to Decrease your Stress and Improve Your Health

Anyone out there feeling extra stressed lately? No? Just me? Great…

In reality, I think I’d be hard pressed to find someone who hasn’t been unusually stressed out this year. 2020 has been a veritable buffet of stressors - there’s been something for absolutely everybody. Job insecurity? Check. Overworked and underprotected? Check. Fear for your children? Check. Fear for your aging parents? Check. Fear of death or disability from a mysterious illness no one fully understands that is spreading like wildfire through the world? CHECK!  Loneliness, isolation or stuck in the house with your entire family for months on end? Check, check and check. For even the most stoic of individuals, 2020 has shaken us to our core, and more than likely, given each of us more than our fair share of things to worry about. 

Stress is a fact of life. In fact, some stress is actually helpful. Our bodies are designed to respond to stress in a way that keeps us safe in the presence of impending threat or danger. But while the experience of stress is natural and unavoidable, stress is meant to be experienced in the acute state: ‘Oh, is that a bear? I better prepare to run. Body: Send blood to my extremities, shut down my immune system and digestion. Get my heart pumping and let’s get some extra glucose circulating so I can move even faster.’ However, the body is not designed to react in an adaptive way to chronic stress. All the physiologic reactions to stress (increased cortisol, glucose and adrenaline release) act to shunt resources away from non-essential functions like the immune and digestive systems, to redirect the body’s resources to systems involved in response to the present physical threat. The cardiorespiratory system revs up, increasing the heart rate to pump more blood into circulation and triggers you to breathe faster to increase oxygen uptake to respond to increased energy demands. Blood (and the oxygen and glucose circulating within the blood) is sent to the extremities and large muscle groups to prepare to run or fight. While these physiologic reactions are super helpful when you’re face to face with a bear, they can be quite maladaptive and destructive to your body when they don’t shut off after the source of stress has been resolved (like in response to chronic anxiety) - or in the case of 2020, if the stressors just keep coming. 

Exposure to chronic stress results in an increased state of systemic inflammation. And again, while inflammation can be a good thing (it is how we heal from a cut or virus or other invading pathogen), chronic inflammation is associated with nothing but bad outcomes. Chronic systemic inflammation has been linked to increase risk of cardiovascular disease, metabolic syndrome, diabetes and cancer. It is associated with the development of arthritis, Alzheimer’s, IBS and a host of other bodily dysfunctions. It is one of the primary theories linked to aging in general. And also, it makes you feel like crap. Chronic inflammation increases aches and pains, disrupts your sleep and increases anxiety and depression. So, if you haven’t been feeling yourself this year, you can probably chalk it up to chronic stress, systemic inflammation and the fact that your entire life and physiologic sense of homeostasis is TOTALLY OUT OF WHACK. 

Now, (and I say this with total lack of judgement because I 100% fall into this camp) some of us think that ‘we can handle it’ or that living a busy, stressful life is simply your status quo. While this may be true, this doesn’t mean your body is handling it any different then the rest of us frazzled, stressed out hot-messes (I also fall into this camp sometimes, too. Lucky me.) Whether you’ve got your make-up on, kids out the door (or at their zooms) and to-do list half finished by 7am, or you’re simply struggling to find the motivation to pour a cup of coffee and deal with the mess you’ve left from the night before, under the surface, we are all the same. When we don’t address how we respond to stress, our body experiences inflammation. No matter what. And as I briefly explained before, inflammation causes disease and dysfunction. So what do we do about this? How do we stop the cycle?

Personally, (and I’m writing this partly to give myself a concrete stress-reduction plan) I suggest trying to reduce stress in two ways. First, I think it is critical to find ways to interrupt the stress-response cycle. This requires two steps - learning to identify when you are experiencing stress, and making the choice, then and there, to ‘change the story’. Second, it is important to minimize the state of systemic inflammation throughout your body, not only to promote improved health, but also to set yourself up to better respond to stress in the first place.

Interrupting the stress-response cycle:

The first step in interrupting the stress-response cycle is to identify that you’ve begun to feel a reaction to stress. Note that I didn’t say identify the stress. The stressor itself is immaterial, it doesn’t matter if it’s a bear or a work deadline. Your body responds in the same exact way (though in variable degrees of severity). Try to notice next time you encounter a stressor what happens in your body. Do you get tense and find your shoulders riding up to your ears? Does your heart race? Do you get a headache or experience nausea? Some people get strong somatic responses - increased heart rate, flushing, muscle tension, headaches or other bodily responses. Other people (myself included) experience more emotional responses. You may feel angry, overwhelmed, irritated or worried. Try to make a list of your specific stress responses and then try to be mindful of these throughout the day. The first step in interrupting the stress-response cycle is simply identifying when you are experiencing it. 

The second step is to change the story. In my experience, this is the most helpful thing you can do right now to reduce the effect of stress on your body. By consciously changing the way you react to the stressor, you change the way your body perceives it. This is the key to stopping the cascade of the physiological responses that lead to systemic inflammation and the physical effects of stress. I learned to use this technique when I experienced sudden onset tinnitus last year. Everytime my ears would start to ring, I’d panic. The anxiety and panic would worsen the experience of the tinnitus, and the worsening of tinnitus would increase the feelings of anxiety. See the problem here? The key to curbing my tinnitus was not getting rid of the stressor (as often, we can’t), but changing my reaction to it. When I would notice the ringing, I taught myself to stop and listen to it. I’d simply identify it for what it was, literally tell myself this is a symptom, not a crisis. This is a sound, not a bear. Then, I’d take a few minutes to listen to the ringing while taking slow deep breaths. Within a few days of practicing this behavior, the ringing didn’t trigger the panic response anymore, and eventually, the tinnitus improved. Even though I still am aware of the tinnitus at times,  it no longer initiates the stress, panic, inflammatory cycle for me, it’s just simply ‘there.’

You can adopt this two-step stress reduction plan to address any stress you encounter. Whether it’s pain, background noise, or demanding coworkers or children - when you identify the onset of the physical effects of stress, stop. Stop and identify the stress for what it is and remind yourself this is not a crisis, or a threat or an oncoming train. Then, take whatever actions best help you retrain your body to enter a state of calm, instead of a state of fight or flight.  If the deep breathing works, great. If you respond well to meditation, use that. Take a walk, go outside, read a book, write in your journal. Whatever you associate with calm, substitute that behavior for your instinctual response to the stressor. It takes practice, but your body will adapt and you can extinguish this response, despite how automatic it may initially be.

Decreasing systemic inflammation: 

Lastly, find ways to lower your systemic inflammation. According to the American College of Sports Medicine, there are four methods to decrease systemic inflammation. First is to take anti inflammatory medications. Second is to ingest antioxidant foods and supplements. Third is by caloric restriction. And the fourth is to exercise. Guess which is the most effective? Exercise. No joke. How great is that? The most effective solution to reduce inflammation is something you can do on your own, for free, right now. It doesn’t even need to be aggressive exercise! Low impact steady state cardio has been shown to reduce cortisol levels and is great for stress-reduction. More moderately intense exercise has even greater benefits on your mental and physical health. Effects start right after you exercise and last hours, and are cumulative over time. There is literally no downside to making exercise part of your regular routine. There is also substantial evidence there are benefits in following an anti-inflammatory diet (like the Medeterranean diet), getting adequate sleep and practicing habits like gratitude, yoga and other mindset-shifting activities daily. You don’t need to follow a guru or pay thousands to a health coach to get in these habits either. Just sit down, in the morning, and try to write a few things you’re grateful for. Make time to exercise. Drink plenty of water. Go to sleep on-time. 

So, am I writing about this because I am a stress-management expert? No. I’m writing this because I’m a frazzled, stressed out control-aholic trying to manage my home, my children, my career and my life in the middle of a dumpster fire of a year. I’ve turned to my vices more often than I’d like to admit, found myself grumpy, irritable, achy and run down and I know perfectly well that this is because I’ve been letting my reaction to stress run the show, instead of using these strategies to change the story. 

I hope you find this information useful and these strategies helpful. Not only do I find that these techniques help me, but these are skills I teach to my patients who struggle with pain management and anxiety related to physical dysfunction and disability. Of course, my advice does not take the place of the advice of your doctor or other clinical professional, and if you feel like your level of stress is unmanageable, please reach out to those individuals for help. And if you see me somewhere staring off into space taking nice slow breaths, now you know why:)

#justtryingtokeepmyishtogetheroverhere

Med A, Med B and HAE; Clearing up the Continuum Confusion

Confused about your Medicare benefits? You’re not alone. But breathe easy and read on as I clear up the Continuum Confusion and help you understand the When, Why and Wheres of Med A and B coverage and how HAE/PT can better help you manage your health, wellness and rehabilitation.

The Care Continuum:

My work in rehabs, outpatient centers and home health agencies has made me increasing aware, and frustrated by, the issues that arise when patients are treated within the constraints of the current medical model. Let’s jump right in by letting me describe for you a what a typical patient experience looks like after a fall.

Mary falls at home, breaks her hip and winds up at the hospital. She undergoes emergency surgery to fix the hip, stays in the hospital for a week until she is ready medically stable enough to leave. If she is lucky, and has family support and a lives in a safe environment, she may go straight home with home health services. If home is unsafe or she cannot yet care for herself, she may go to a rehab hospital or skilled nursing facility for another week or two. Once she is home, home health sees her for four to eight weeks to help her heal from the surgery, to get a little stronger and work on the skills necessary to return to her baseline level of function. (Side note: ‘baseline level of function’ does not necessarily mean she was functioning in the best possible state in the first place). In an ideal world, Mary can now go to outpatient PT to continue her recovery. 

However, for many patients, this is where the problems start. Home health PTs are required by Medicare to discharge as soon as a patient is no longer homebound, if they have met their goals or if they are no longer making progress. Mary, and so many other patients like her, are often left simply with the instructions to schedule therapy at an outpatient center and continue with their home exercise program until then. But the reality is that even though Mary may no longer be technically be homebound, getting to an outpatient clinic may remain quite difficult. It requires getting dressed, may involve getting up and down stairs, walking outdoors and finding someone to take her - with a lot of pain in the process. Multiply this by two to three visits a week for another six to twelve weeks and then add in the reality of  life in New England. This may be feasible in spring and fall, but what if you’ve fallen over the  winter? Now you’ve got ice, snow and everything in between to contend with. You’re probably starting to see where I’m going with this.  Before we talk solutions, I will review some Medicare basics, because quite honestly, it’s taken me twelve years as a therapist to even begin to understand them, so I can only imagine the frustration patients feel every day having to make sense of this themselves.

Medicare A Benefit:

Your Med A benefit pays for services you receive while you are in a hospital, or if you require services after a hospitalization and you are ‘homebound’ and cannot access services in the community. To be considered homebound, leaving home must require considerable and taxing effort. You either require the help of another person or medical equipment to enable you to leave home, or leaving home places you at risk of injury or medical complication. Basically, you only leave home to go to the doctor, to attend a religious service or a family event and only on occasion. It also allows you for you to take trips to the barber shop or hairdresser, which I’ve always found amusing. This part of your coverage pays for services received at the following places:

• Inpatient Care Hospital:

• Inpatient Rehab at a Rehab Hospital or Skilled Nursing Facility Care

• Home Health Services

• Hospice Care

Medicare B Benefit:

Your Med B benefit covers ‘medically necessary’ outpatient physical therapy services. The term medically necessary means a clinician must that certify you require skilled Physical Therapy services to treat impairments and limitations due to illness or injury. Medicare pays for 80% of these costs; you, or your supplemental plan, is responsible for the remaining 20%. You can choose where you use your outpatient benefit. There is no cap on how much Medicare will pay for outpatient services per year, as long as your therapist demonstrates the treatment is medically necessary - and that you have potential to reach your goals and are continuing to make progress. This part of your coverage will pay for you to receive care at the following places:

• Outpatient Rehab

• Mobile PT (like HAE/PT!)

Beyond the Benefit: 

When you no longer qualify for physical therapy services because you have either met all of your goals, or no longer have a skilled need, you can either discharge from therapy and continue with your home program on your own - or you may consider continuing on with a therapist either on a maintenance program or for other wellness programming. The options here are varied, but very worthwhile to consider. You can choose to continue with a clinic physical therapist or a Mobile physical therapist like HAE/PT, under a Medicare-covered Maintenance program if this applies to you , or pay privately for continued services as a Wellness Program if it does not. You could also attend local exercise classes or a join a gym. Either way, it is imperative you find a way to continue to stay active and on your exercise program after therapy ends to maintain your gains, prevent future decline - and stay healthy!

There has got to be a better way…

While these above explanations hopefully clear up the confusion, I want to talk more about the Care Continuum and why I started HAE/PT. After seven years of seeing ‘Marys,’ and so many patients like her, I started to think there had to be a better way. What if there was a PT who continued to come to you, to work not only on healing from your injury, but more importantly, on the thing that got you here in the first place - the deconditioning, progressive weakness and increased fall risk that happens with aging if you don’t stay active! While balance training may be a part of home health PT, it often is just that - a small part. Overall fitness assessment and training is even further out of the realm typically provided by home health services. The role of hospitals and home health is to dealing with the priority needs - addressing your acute injuries or illness exacerbations and reestablishing your functional independence. HAE/PT was born of the idea that we can do better. We can do by better addressing your whole health, your overall fitness level and by helping you to decrease your risk of falls. We can do better by educating you on your health conditions and how you better manage them - and prevent them from getting worse. We can do better by giving you the tools - and the ongoing support - that you need to keep yourself healthy, happy and whole. What if you could have a physical therapist, who gets to know you like your doctor does? A physical therapist who you could check in with when things start to slide a little, or if you start to feel worse or better yet, if you’re still doing great and just want to make sure you’re still performing your Wellness Program effectively. This is why I started HAE/PT. I want to be able to be this physical therapist for you. 

Have more question or want to get in touch with me or to set up a phone consultation? Just ‘say HAE!

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the time I had to participate in family yard work day…

totally not my house, but the weeds were the same…

I’m not a fan of yardwork. I won’t go so far as to say I hate it, but I don’t get any joy from it. I don’t love the dirt, I’m not a huge fan of the bugs and every time I’ve ever put effort into creating a garden, it has become absolutely decimated by hungry rodents in less time than it took to plant the stupid thing. But lo and behold, last week, I found myself begrudgingly taking part in family yard clean up day. And by ‘family’, I mean me and my husband weeding and raking and mowing and scooping and wheel-barrowing for 6 hours straight after my kids pulled weeds for 10 minutes declared it was too hot and went inside for popsicles. But I digress.

‘So, Katie, why are you posting about yard work in your PT blog?’ Welllll…during the 6 lovely hours I spent weeding and raking and mowing and wheelbarrow pushing, I had a lot of time to think. And I thought a lot of about functional strengthening. I’ve been on a functional strengthening kick lately. I’ve come to love how it feels in my own body to focus on functional strengthening exercises, and have begun to utilize this form of exercise more and more often into my therapy sessions with my patients. I love it because it just plain makes sense. Why work a one single plane exercise, when you can use a movement, that not only involves all the major muscle groups, but mimics every day movements to encourage carryover to function? If I’ve already started to lose you, you may want to take a moment and read back to my initial post on functional strengthening What is ‘Functional Strengthening' and Why Does it Matter?'

Now I’m not sure what your weeds are like, but let me tell you, our yard has been overrun by some monsters lately. These things have vines and flowers and they are expansive. It took some serious effort to get these bad boys out of the ground and I soon found myself doing what felt like weighted squats and deadlifts and before I knew it, I was involved in a complete functional strengthening workout - right in the middle of my front yard. I spent the next few hours analyzing each task and found myself in awe and wonder of how much each yardwork task involved the six primary functional movement patterns. These movements, the squat, the lunge, push, pull, hinge, and twist were involved in every task I completed - and the workout I got was pretty damn impressive considering it didn’t involve a single weight, band, or kettlebell or anything else I normally use to get my strengthening done.

Functional Movement Patterns

◦The Squat

◦The Lunge

◦Push

◦Pull

◦Hinge

◦Twist

Without further ado, I present to you, a full yard cleanup workout plan:

Squat: Instead of sitting to weed, squat and pull, squat and pull, squat and pull and repeat. Take two steps to the right and perform your second set.

Lunge: Find a large hill. Push the mower up said hill and enjoy endless alternating forward lunges. You’re welcome.

Push: Put aside the ride-along and push a mower across your yard. Bonus points if it isn’t self-propelling. Load a wheelbarrow with weeds, then push to dump them behind your fence for the sled-push version of this exercise.

Pull: Rake. Rake. Then rake some more. This exercise can also be used in fall to get rid of excess leaves.

Hinge: Once you have completed your raking super-set, keep your back straight and hinge at the hips to pick up the piles of your yard crap.

Twist: Twist to load these piles into your wheelbarrow, then return to your Push set as a finisher.

Be sure to tune in next week for my next installment of things I think about when I’m bored ‘How to Workout While Also Getting your Laundry Done.’

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