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Plantar Fasciitis and Ultrasound: questionable at best

“The plantarfascia is a thick, nonelastic, multilayered connective tissue crossing the plantar part of the foot. Plantar fasciitis is the main cause of pain in the plantar surface of the heel.”

The plantarfascia is located at the bottom of the foot, between the heel and the toes.   It is very thick and a tough band.

A part of physical therapy school includes dissecting the human body.  Some people find this disgusting, but it is actually an honor.  We were told that only 5% of college students will ever be able to dissect the human.  The bottom of the foot is very intricate. There are multiple layers of muscles, but the plantar fascia is a very taut band that requires a scalpel in order to tear.  In other words, it is very strong tissue.

“In the United States, more than 2 million people are treated for plantar fasciitis every year…the most common signs for identifying plantar fasciitis are pain and tenderness in the medial …heel bone, as well as an increase in pain when taking first steps in the morning and pain in prolonged weight bearing.”

First, plantar fasciitis is mostly diagnosed through a patient’s history.

Second, there are a lot of people with plantar fasciitis that seek out treatment.

This leads us to the next statement from the article

“…researchers have not determined the most effective combination of treatments due to the dearth of high quality research in this area.”

Feel good about this condition yet? So many treatment options are available, but few with solid research to back them up.

If you are interested in learning more, check out this  Link

“One of the most widely used electrical devices among physical therapists in Israel and worldwide is therapeutic ultrasound…Yet there is insufficient high quality scientific evidence to support the clinical use of therapeutic ultrasound in treating musculoskeletal problems.”

I find it funny that PT’s should know this information and yet they act opposite of what the evidence indicates.  There are running jokes that using ultrasound may be just as effective turned off as when turned on.

If your PT continues to utilize ultrasound, ask why?

Sometimes the answer may simply be: it is easy, it can be charged and it will do no harm.

Treatment:

Both groups were given stretches for the Achilles/calf and the plantar fascia.  One group was issued ultrasound at a higher intensity in order to create a thermal effect and the other group was given ultrasound that was low intensity and not postulated to have any physiological effect, as the intensity was low and the depth of treatment was considered more superficial.

There was no significant difference in the number of treatments per group.

Result: There was no additive effect of ultrasound on the treatment of plantar fasciitis for pain, function or quality of life.

There are reasons to use ultrasound from a business perspective, but the more and more that I read research I find fewer reasons to perform the intervention medically.

Reference:

Yigal K, Haidukov M, Berland OM et al. Additive Effect of Therapeutic Ultrasound in the Treatment of Plantar Fasciitis: A Randomized Controlled Trial. J Orthop Sports Phys. 2018;48(11):847-855.

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ACL rehab

“At 13 months post ACLR (Anterior Cruciate Ligament Reconstruction), individuals exhibited average knee extensor moments that were 17% smaller in the surgical limb during a bilateral squat against body-weight resistance”

ACL injuries tend to be noted in some non-contact sports such as soccer and basketball. Contact sports, such as football, also have ACL tears noted during contact, such as a tackle that makes the knee buckle inwards.

The patient with an ACL tear will typically opt for surgery if he/she plans on returning to some type of sporting activity. There is a debate as to whether or not to have the surgery if there will be no return to sporting activity.

After the ACL surgery, the research above notes that patients are less likely to use the surgical side during a squatting activity (think getting up from the toilet) and will push more with the non-surgical side.

This makes sense to me. After the surgery, the patient is in a locked long leg brace and is unable to move fluidly on the affected leg. The patient will not spend as much time on the surgical leg because of this and will transfer the weight to the non-surgical side. It becomes a learned habit to transfer the weight to the non-surgical side, but this is just my opinion.

 

“The persistence of under-loading is concerning, as asymmetrical limb loading during landing tasks has been linked to increased risk for anterior cruciate ligament (ACL) reinjury”

This is important! If we never get the patient to load the leg in order to improve strength and motor control (ability move in the way that the brain dictates), then the patient is at a higher risk of future injuries.

Let me clarify: if you squat and allow your legs to go wet noodle during the squat, it will look like a knocked-kneed version of a squat. This is not inherently horrible, but when asking the body to absorb a large load in this positon, when not trained to absorb this load, may lead to an injury. It all comes down to progressively loading specific positions in order to learn how to hold this position.

This is a major component of Olympic weightling compared to powerlifting. In the performance of the snatch (the most explosive movement in sports), maintaining proper position is extremely important for completing the lift. In powerlifting, the position may be able to be off a little and the athlete can overcome the small error in position.

With regards to ACL rehabilitation, it is important that we ensure that the patient is able to have enough strength to maintain positions without the load (bodyweight jumps, external weight, etc) dictating positional changes.

 

“…the bilateral multijoint nature of a squat allows for compensations that can shift the task demands to the nonsurgical limb (interlimb compensation) or to adjacent joints within the surgical limb (intralimb compensation) to reduce knee extensor moments.”

The bodyweight squat can be performed differently and switches the load from either the hip to the knee.

If you watch someone squat (recommended for all people that will attempt to squat), the person should both watch the knee and the hip. If you look at opening and closing, this will be much easier.

  1. Watch the knee to see how much the knee “closes” or how much the angle changes from the calf to the hamstring
  2. Watch the hip to see how much the hip “closes” or how much the angle changes from the trunk to the thigh

Which joint moves more?

This will help the reader to understand whether the knee joint muscles or hip joint muscles will be the dominant movers during the squat. Those that have knee issues will tend to move the hip joint muscles more than knee joint muscles.

I’ll make a video on this at a later date.

 

“…individuals 1 month post ACLR performed bilateral sit-to-stand tasks with a 38% reduction in vertical ground reaction forces (vGRFs) in the surgical limb”

This very simply means that the person is pushing less with the surgical leg than the non-surgical leg.

This means that the surgical leg is taking less force through it and will not be able to generate the same amount of power. Also, it is typical to see the patient weight shifting towards the non-surgical leg.

“reduced knee extensor moments have been found along with increased hip extensor moments…may rely on interlimb compensations to unload the knee during early rehabilitation but adopt intralimb compensations as they progress through rehabilitation.”

This goes back to the differences in a powerlifting based squat and an Olympic weightlifting based squat. The more upright the torso, the more that the knee takes a load and the less upright the torso, the more the back and hips will take the load.

I am having this exact conversation with a patient currently following an ACLR, attempting to get the patient to increase the load on the knee.

“During early rehabilitation, strategies for restoring symmetrical weight bearing during bilateral tasks should be emphasized and reinforced even during submaximal tasks…efforts should be made to continue to focus on sagittal plane knee loading and avoid compensation with the hip extensors.”

I tend to use a mirror for visual feedback in order to allow the patient to see the weight shift between the legs. This tends to fix the problems for weight shifting. We then progress to doing the squatting motion away from a mirror in order to build in positional awareness without the need for visual cues.

In order to improve the knee to hip ratio regarding which joint moves more, the cues will switch from sitting back on a chair (similar to a box squat which is hip hinge emphasizd) to emphasizing sitting between the feet (similar to an overhead squat) which is more knee joint driven.

If you don’t have a PT that understands how to squat, this may be a difficult movement to restore with physical therapy alone.

It may be prudent to ask your PT to describe a squat prior to starting therapy in order to ensure that your therapist has at least a baseline knowledge of squatting.

If the therapist doesn’t start describing multiple techniques for squatting based on body shape, then the therapist may not be well versed in the movement.

If you have any questions about squatting or ACLR rehabilitation…comment below.

Article: https://www.jospt.org/doi/abs/10.2519/jospt.2018.7977

 

You can find me at Primarycarejoliet.com and wherever you subscribe to podcasts at A physio’s perspective: movementthinker.

Second opinion

How many people will choose to get a second opinion before going in for a major surgery?

I would hope 💯%!

I had an awesome conversation about 10 years ago when I was visiting Canada. There was a guy that traveled to Canada in order to get an opinion regarding back surgery. He was from San Diego. That’s a pretty far trip to see if he needs back surgery.

I asked him why travel that far for an opinion and he said that he wanted to reduce any bias on the doctor’s part regarding whether he was a candidate. For instance, the doctor in Canada would not be performing the surgery and it was unlikely that the doctor giving the opinion would be able to benefit from recommending surgery, since the patient would have surgery in California.

He avoided going for the opinion in California because the hospital system would profit from the surgery. The surgeon may have an arrangement with the hospital to ensure that the hospital gets a percentage of the money. We know that the hospital will make money during a surgery. Many people stand to profit from a surgery and the patient would do well to get an opinion from someone that doesn’t stand to benefit.

This brings me to my rant for now. 👇

Why don’t patients get a second opinion regarding physical therapy?

1. It’s not a huge expense

Physical therapy, on average will cost the insurance company about $1200 per episode of care. If the patient is paying 20% for the coinsurance, then it will only cost the patient $240/episode. This works out to about $50/week.

That’s relatively inexpensive compared to a large surgery. The question is: why not spend an extra $25 to see if a second therapist agrees with the first? If there is a disagreement in how treatment should be performed, then the cost may not be the chief factor.

This leads us to 👇

2. All therapists do the same thing

Not all PTs are trained the same! Don’t let a non-PT (such as surgeon or family doctor) tell you that it’s all alike.

Not all surgeons have the same reputation and skills. Not all PTs have the same reputation and skills. The only way that you, as a patient, will know about other’s skills and reputation is to ask and try.

If you are absolutely in love with your PT or MD, then so be it. Sing from the rooftops so that the reputation gets built. If you’re not…try someone different.

Sometimes the grass IS greener.

3. Convenience

I get it. A drive around the corner is much easier than a drive for an hour. It makes sense.

If we believe that not all therapists have the same training or passion for treating a specific issue, then we must also believe that these therapists are worth the drive.

Follow this example:

1. Patient A decided to go to a therapist close to home or work (we know that regarding gyms most people won’t drive more than 15 minutes from work/home). The therapy session costs the patient $240 out of pocket and the insurance pays $1000.

Let’s also say that the patient is being seen for low back pain or sciatica, since this is the number one reason to seek PT. The patient is seen in a clinic in which the therapist is there to punch a clock and see as many patients as possible because that’s how 💰 is made.

The patient doesn’t get much better and then returns to the doctor for a series of shots (more money and time). The shots are a 50/50 chance of working.

Half of the patients will then still have pain and now be shuffled to the next step, either pain management or surgical consult.

2. Patient B spent a little time to search for the therapist in a 20 mile area that best treats low back pain or sciatica. The patient makes an extra 20 minute drive. The therapist decides that the patient would ben for from 8 visits of PT over 6 weeks and the patient gets better because the therapist enjoys the job and works well with patients having this diagnosis.

The patient made a little more of an effort up front, but saved 💵 and ⏳ by choosing the right therapist instead of moving further along in the medical system.

Want a second opinion, send me a message.

Considering a nursing home after surgery

“Moreover, older adults who are hospitalized are 60 times more likely to develop a disability than those who are not. ”

This is HUGE!

We know some of the common statistics such as an adult over 80 years that falls and breaks a hip has a high likelihood of death within one year.

There is some research about reserve capacity and the body’s ability to withstand a major obstacle such as a fall or hospitalization. Reserve capacity is essentially the amount of ability that a person has that exceeds daily needs.

For instance, if you typically walk 2.5 mph, but have the ability to walk at 5 mph, the reserve capacity would be the difference between usual speed and RESERVE gait speed.

“… recovery of function during a SNF stay is inadequate under usual care”

I’ve worked in a SNF and will attest to this based on experience. I stuck out like a sore thumb during my time in the SNF.

I got many of my patients up and walking. I would stand next to the patient to motivate, encourage and correct any safety issues that I noted during a movement or exercise.

Many of my “peers” were sitting at computers about 20-30 feet away from patients barking out directions from across the gym. The atmosphere was more party like for the roles of professionals, in which many conversations revolves around personal lives of the therapists, instead of the patient.

“The 2017 Medicare payment advisory commission reported no change in functional outcomes as measured by a patient’s ability to perform bed mobility, transfers, and ambulation.”

This is crazy! A patient goes to a rehab unit in order to rehabilitate to a safer functional level. If there are no changes in outcomes…why bother!

I did some research on total knee replacements when creating the protocol for our outpatient facility and there was much research showing that patients that went home after surgery did better than those that went to a “SKILLED” nursing facility.

Again…why bother!

There may be some lower level patients that need the nursing care at a facility like this, but we really do need to do a better job of planning a patient’s discharge from the hospital.

“specifically in SNF’s, annual expenditures comprise 50% of the $60 billion US allotted to post acute care. The discrepancy between high levels of spending in SNF’s and sub optimal outcomes strongly suggest the need for innovative clinical research designed to advance models of care delivery and assert the value of SNF rehabilitation therapists”

☝️ 🤔🤑

Leaving this one to stand on its own.

“… hospital discharge patterns away from SNF towards less costly home health or outpatient services.”

This makes sense and we are seeing this happen for some orthopedic cases that would previously be sent to a SNF. It took incentivizing hospitals and physicians to get them to change the way they treat patients.

“Nursing home literature suggests patient motivation to participate in treatment, such as physical therapy is linearly correlated to patient perceptions of and satisfaction with support from peers, family, and staff.”

Wonder why some patients may not be motivated to work with staff?

Read this article.

Excerpts from:

Gustavson AM, Boxer RS, Nordon-Craft A et al. Advancing Innovation in Skilled Nursing Facilities through Academic Collaboration. PTJ-PAL. 2018;18(3): 5-16

Back pain using MDT

“Low back pain is the worldwide leading cause of years lived with disability, with an estimated point prevalence of 9.4% and a lifetime prevalence of up to 39%”

If three people are sitting together, the odds are that one of those three had back pain, has back pain or will have back pain. That kind of sucks, unless your the one of the people without pain.

Point prevalence means that any one point in time about 10% of the population will have back pain. There are about 320 million-ish adults in the US. This means that about 30 million adults have back pain at any one point in time.

It’s a great time to be a PT, if we can educate the public that we are well trained and capable of treating back pain.

For patients reading this, not all PTs are equal and just like with a surgical procedure, you’d probably get a couple of opinions before making a decision on YOUR Guy or Gal (after you gain trust in the person all of a sudden they become YOURS). I get it! Some people call me their guy, but I’d like for more people to call me their guy.

***tangent: patients are paying more for healthcare. This could be in the form of a higher deductible, copay, coinsurance or straight cash based. As a patient, you should be looking around for the person that gives you the best value for your dollar. If you ever have questions regarding your treatment, feel free to message me and ask me questions in a free conversation. I have a long commute daily and love having these conversations, which have become a weekly occurrence. You can find me Here

“The presence of centralization is associated with good prognosis in patients with low back pain…recent studies have shown that directional preference and centralization, when I matched with adequate MDT treatment, result in better patient outcomes and then treatment with general range of motion exercises”

Centralization?🤔 I wonder what that is?

If you’re new to this page, you can go back and read my old posts on centralization here

Just know that centralization has been called the trump card to helping patients with back pain…it’s that powerful that it darn near always wins for the patient.

“The level of MDT training should also be considered, as it may impact interventions and risk-adjusted functional outcomes.”

Studies have been Published questioning the reliability of using MDT. I believe that these studies need to be looked at in depth because this particular study shows that those not certified in the method may not be the most reliable in noting a particular “syndrome” in the patient’s presentation. The level of training appears to play a role in the therapist’s ability to assess a Patient.

“only trails in which of therapists were MDT trained were included. To be considered MDT trained, therapist were required to have participated in at least one course offered by the McKenzie institute international focused on applying MDT to patients with LBP”

Based on the above research links, just using therapists that have taken courses in MDT decreases the likelihood that a reliable classification took place, therefore reducing the likelihood that the patient was treated according to the proper principle and finally leads me to believe that I was wasting my time in reading the remainder of the article….I digress. I read it anyways to hear what’s being talked about regarding MDT, both good and bad.

“review were’s screen 354 abstracts and selected 51 articles for fall text review. After review, 17 articles were retained for the meta-analysis; however, of these 17 studies, four did not provide sufficient data to be included in the statistical analyses”

This is part of the problem that I have with systematic reviews and meta analyses. So much of the research gets discarded and not used in the actual article, that we then start to see researcher bias based on the question asked and how the researchers go about obtaining information. Think of it, only 5% of the actual information that they found on their initial screen actually makes it to the cutting room floor.

“MDT versus manual therapy plus exercise: there was moderate evidence of a significant difference in pain after the intervention, with results favoring MDT…There was moderate evidence of no significant difference in disability after the intervention period between MDT and manual therapy plus exercise.”

I think this is 👌. Understanding that MDT is the assessment first and treatment second one must also understand the components of MDT. MDT incorporates manual therapy, exercises, postures and positions. This means that there is something specific to the way that manual therapy and exercises are prescribed in MDT that has a greater affect on pain that just manual therapy and exercise together.

No effect on disability or function over a time period is also not surprising for me. It’s well known amongst those of us that use this method that returning a patient to function is not well taught in MDT, as there are many other courses and methods that speak to this. MDT follows a certain paradigm, with returning to function as part of the paradigm, but because it varies widely from patient to patient, it is best learned from other resources.

“this study found that MDT plus first – line care resulted in significant, but small, improvement in pain intensity compared to first – line care only.”

This is significant! But small. For anyone going to an ED for back pain, they are in significant pain. I’ve spent part of my career working in an ED for this exact population. In the time I worked in the ED, only one patient was unable to find a position, movement or posture that provided relief. This is significant because these patients were able to receive the right care through an outpatient means instead of being admitted to the hospital for “non-specific low back pain”.

These patients didn’t receive the rapid MRI, which in some cases may actually make the patient worse over time. These patients didn’t have a hefty hospital bill and these patients were able to recover in their natural environment thereby reducing the risk of infectious disease acquired in the hospital.

This is significant!

“One study included in the review, despite lacking data for analysis, compared MDT to education and found no significant between – group differences for changes in disability.”

This is not too shocking for me. If the pain is acute (started recently), we know that many with back pain will get some relief over time. Education is powerful in and of itself and a large part of MDT is education based.

If both utilize education as the base for acute pain, then the outcomes may not be much different. No shock here!

“There was moderate evidence of a significant difference in pain after the intervention period, with the results favoring MDT. ”

MDT is a patient response system. This means that after every movement, position or posture the therapist is asking the patient if it reduced symptoms. If the answer is yes, then the PT will typically issue this for a home program. 🙄

It’s no wonder that the system is pretty good at reducing pain in a specific classification; the therapist is giving exercises that have been shown to reduce pain/symptoms.

“Two studies included in the review, which lacked sufficient data to be included in the meta-analysis comparing MDT to modalities, found significant between-group differences for changes in pain, favoring MDT.”

Again, comparing an active intervention (patient takes part in the intervention) to passive interventions (treatment is done to the patient) is expected to lead to an outcome favoring the active intervention. There are multiple reasons for this, but one may simply be interactions with another individual during the session.

“Three studies compared the effects of MDT to combined manual therapy plus exercise in participants with chronic LBP…There was moderate evidence of no significant difference in pain after the intervention period between interventions…There was high quality evidence of no significant difference in disability after the intervention period between interventions.”

Again, this is not too difficult. As a treatment strategy MDT is literally manual therapy plus exercise. It’s comparing two similar interventions, with similar results.

“One study had 2 comparison intervention groups consisting of either MDT exercise in the opposite direction as the directional preference or midrange lumbar/stretching exercises. Only this latter group was included as the comparison to MDT in the current analysis.”

This is the part of the analysis that I don’t quite understand. Why bother 🤷‍♂️ comparing the interventions if one of the treatment groups is removed?

This article is cited frequently by PTs trained in MDT and you can read my analysis of the article Here

Removing one of the groups, specifically the opposite directional preference group, greatly changes how that article impacts the reader.

“There was high quality evidence of a significant difference in disability after the intervention period, with the results favoring MDT.”

Even with removing the group of patients that had a high dropout rate and poorer outcomes, the article still favored MDT over “evidence based” interventions.

“Also, MDT does not explicitly account for pain systems theory, specifically differentiating between pain that is central or peripheral in origin, and for a wider spectrum of psychological factors that could be present in patients with chronic low back pain. ”

This is a good point and those that are well versed in the system would state that there are other classification systems out there that would include this pain system. If you are interested in these systems, I highly encourage readers to take a course by Annie O’Connor, author of A World or Hurt.

You can learn more about Annie by following this Link

Thanks for reading.

Since my last post, I’ve gone through a major job change. I can now be found at PCJ

What would it take to convince you as a patient to give a PT with an MDT certification a chance?

What would it take to convince you as a PT to take an MDT course?

Link to article

A Penny saved is a penny earned

We’ve all been there! That place in which we are sinking instead of swimming. You ain’t alone.

Hear my story below.

Check out my episode “A penny saved is a penny earned” from Movementthinker: a physio’s perspective on Anchor: https://anchor.fm/vincent-gutierrez/episodes/A-penny-saved-is-a-penny-earned-e298p5

PTA’s in an outpatient setting continued

“Low back pain syndromes (LBPS) affect more than 65 million Americans…For approximately 16 million people (8%), back pain is persistent or chronic…”

If you have a little bit of free time, you can read about back pain here.

“…a quarter of all referrals for outpatient physical therapy and one-half of all outpatient physical therapy visits are related to patients with LBPS.”

Hey New Grad ✊ are you 👂?

If you want to get really good at something and ensure job stability, then you should learn as much as you can about back pain.

If one out of every two visits per day is related to back pain, we should all be very comfortable with this diagnosis.

In my first job, I’d say that I had 2,500 visits per year with about 95% of those pertaining to the spine.

“Resnik et al reported that patients who spent more than half of their treatment episode of care with a physical therapist assistant reported worse functional outcomes and utilized more visits compared with patients with less physical therapist assistant involvement.”

Again, this is the second post in the series on PTA’s usage in the outpatient setting.  You can find the first post here.

“It is generally assumed that practitioners must possess many years of clinical experience to achieve the best results with patients and that years of experience are associated with better clinical outcomes.”

What?! I don’t agree with this.

Unfortunately, not all experience is good experience. I’ve read Tony Delitto state in an article that one year repeated twenty times is it ideal. I would much rather have a PT with two years of experience and two years worth of learning from mistakes.

“Almost half of the sample had chronic low back pain.”

This is in line with some of the statistics that I’ve heard stating that back pain makes up about 40% of all chronic pain.

“The top 3 diagnoses were pain (34.8%), sprain or strain (25.5%), and herniated disk (19.3).”

About 90-95% of all back pain is “non-specific”, meaning that we can’t attribute it to a specific tissue strain or sprain. Herniated did a are common in the population, but we can’t always attribute a herniated disc (HNP) as the cause of pain.

“On average, patients in the best clinic performance group improved 19.2 OHS points, while patients in the worst clinic performance group improved an average of 16.4 OHS points.”

This is great news!

This means that on average people get better. I used to work in a clinic in which the manager would try to schedule people with back pain as soon as possible. If we know that they will likely improve and they improve on our watch, then they are likely to use post hoc reasoning and attribute improvement to seeing the PT.

I used to joke with patients and say that they simply need to breathe the city air in the basement of the hospital in order to improve. Obviously, it’s a joke, but we have to tell patients that most injuries improve with time.

“Patients in the best clinic performance group utilized, on average, 7.7 (SD = 4.1) visits per treatment episode compared with 7.9 (SD = 4.1) in the middle clinic performance group and 9.3 (SD = 4.9) in the worst clinic performance group.”

This is where it gets interesting. There wasn’t a major difference in outcomes on the scoring improvement, but some clinics needed an extra 2 visits compared to other clinics, on average.

If an average PT sees 5 evaluations per week and it takes an extra 2 visits, then that ONE PT is averaging an extra 20 visits per month (assuming half of the evaluations are back pain). This means that the therapist keeping patients for more visits is making the clinic an extra $2,000 per month from taking longer to discharge patients.

“…clinics that were lower utilizers of physical therapist assistants were 6.6 times more likely to be classified into the high effectiveness group compared with the low effectiveness group, 6.7 times more likely to be classified into the low utilization group compared with the high utilized group, and 12.4 times more likely to be classified into the best performance group compared with the worst performance group.”

This is essentially stating that clinics that use PTAs with a lower frequency in outpatient tend to be better in terms of outcomes and faster to discharge. This mirrors the link to the study from above.

For me this is interesting because I would have never thought to ask the question in the first place. It’s good to see that someone is doing this research to help clinicians in their decisions to 1. Choose between PT and PTA school and 2. Utilize PTAs and how to best utilize PTAs in an outpatient setting.

“Our strongest finding was that clinics that had lower utilization of physical therapist assistants were much more likely to be in the “best” category of each type of group (i.e. highest effectiveness, lowest utilization, and overall performance).”

Link to article

Rejection

To anyone that has ever felt rejected, you understand.

To anyone that was raised in a single/no parent home because of decisions, you understand.

This scene hits home for me because I have felt that rejection, along with many other kids. This scene plays out in homes regardless of race, income and religion. This scene still affects those that lost parents to addictions, divorce, jail, and choice.

Know that you are not alone and there are many of us that understand. We have been there.

What I still don’t understand is why scenes like this break some people and creates chips on others.

I’ve seen many overcome these situations and go on to become Uber successful due to that chip and having something to prove.

On the flip, I’ve seen some people become so broken that they continue the cycle that broke them.

We all feel rejected at some point.

My wish for the world is that people build resilience and grit in their personality so that these major hurdles become but small bumps as they grow into beautiful people that allow others to love them and be part of that circle of trust.

Check out the video that still makes me tear up.