11/4/2016

An Interview with Heather Southwick, Director of Physical Therapy for the Boston Ballet

Can you give me some background on your education and experience?

My undergraduate degrees were in Dance and Psychology and I have a Master’s degree in Physical Therapy. My job incorporates everything I like and enjoy. I am a dancer and taught it for years when I first graduated from physical therapy school. I worked for Boston Children's Hospital in their physical therapy department. I also did inpatient acute care and outpatient care in most of the different clinics. But part of my position was always to help take care of Boston Ballet, both the school and the company. So, I've been at Boston Ballet now for 20 years.

Almost six years ago, there were changes in leadership at Children's Hospital, as well as changes happening at Boston Ballet. The Artistic Director, Mikko Nissinen, decided to bring physical therapy in-house. This would allow for a little more control over the physical therapy schedule and what the dancers were receiving, versus having a contract with an outside entity like a hospital or private practice. Different companies around the country do things differently depending on their budget, but most companies the size and caliber of Boston Ballet have on-site physical therapists and sometimes a combination of physical therapists and athletic trainers. So, I've worked directly for Boston Ballet now for six years.

How did you first become interested in physical therapy?

When I was younger, my aspirations had been more focused on medical school due to my interest in anatomy. I went to Simmons for graduate school in physical therapy and Mount Holyoke College for undergrad. I found out that I would have a full cadaver at Harvard Medical School which really excited me. Anatomy had always been very interesting to me. Dancers tend to be very well versed in their own anatomy and understanding, because you must be super in touch with your own body. It's the instrument for which you do everything. I think that had a lot to do with my interest in anatomy and ultimately physical therapy. If I had it all to do over again, I would have done a dual degree in physical therapy and athletic training because I do both in my job daily. Even the way that the clinic works now is a lot more like the athletic training room would be in any professional sports team situation. I have a lot of acute care background, both from being in the hospital as well as taking extra courses so that I would be appropriately prepared for the kind of emergencies that sometimes can happen at the ballet, but also have a strong rehabilitation background which helps manage overuse injures and rehabilitation after surgeries when needed.

What does a typical day look like?

My average day varies whether the company is rehearsing, performing, or both. The dancers have a seven-and-a-half-hour day, so they have an hour and a half of class, and typically six hours of rehearsal a day. Which is a lot! I try to add on injury prevention programs, like dynamic stretching, conditioning programs, Pilates or Gyrotonics. We encourage a lot of cross training, particularly depending on the different kinds of ballets that are being done. Ballet class may not always prepare you for the demands of choreography such as push-ups on stage or doing a plank with someone else on your back, so we try to incorporate a lot of cross training. If we're performing, then the day is more focused on what's happening on the stage. There will still be rehearsals for the performance and class, but there's also the performance itself as well so it varies.

On a typical day, I see between 15 and 20 patients. I know them all very well, so that's helpful. I might see them every day, and again that's where there's a similarity with a training room. There are 70 dancers with the company and then our apprentice company which is called BBII, so it can be busy. Some days if we're at the theater it's similar to pre-game concerns in sports and getting everybody out on stage and ready to go. IF we are at the studios and there is not a performance, we try to incorporate preventative care for people who maybe just want to work on something to increase their strength or are noticing difficulty with any particular choreography.

Are you onsite for every performance?

We don't cover every single one. There are 43 Nutcrackers so that would be a little crazy. We have two physical therapists that take care of the company. We stay until curtain, because that's when the major decisions often need to be made if something is going on and the casting must change. For emergencies, we have a physician at every show both for the rare emergency, but also so the doctors can see what the dancers are performing and the demands of a current program. We are somewhat on-call instead so if something happens during the performance and we're not there, then we get called. We end up being there about 50% of the time, just because of the way our schedules work. But typically don't have to be there for the whole show. Because it’s not a contact sport, generally most of our injuries don't occur during performance. Acute things do happen and we're lucky to have a great team of physicians throughout the city of Boston that help take care of the company and are always there to help if there's an emergency.

What is the most common injury you see?

Mostly what we see are foot and ankle issues. The women wear pointe shoes and no other athlete in the world weight-bears on their metatarsals and their tarsal bones in the same way that you do when you're in a pointe shoe. Sometimes we see issues when the women have to change shoes often during the same performance. We are doing a performance now, Le Corsaire, and the women have to wear three different types of shoes in one performance. If they're in the corps de ballet, they might wear generally a flat shoe that's more like a ballet slipper. Then they have character shoes for another role in the ballet, and then may also have to wear pointe shoes. Sometimes switching shoes a lot can cause issues. For the male dancers, it's just there's no support. so we also see a lot more issues in the foot and ankle with the male dancers.

After that, I see a lot of hip issues, and then the spine and knees follow from there. Shoulder issues are not as prevalent, or upper extremity things in general. There may be a lift that didn't go well or a particular choreography that requires incredible amounts of shoulder range of motion, but upper extremities tend to be less. It's more choreography dependent than general issue.

So what's your favorite part about your job?

I would say watching someone get back on stage healthy and returned to performing better than they were prior to the injury. Whether they had some injury that put them in the wings for a long time or even something simple. My favorite part of the job is helping them optimize their performance and do the best they can do. If they do sustain an injury that takes them out, it's really satisfying to see them back on stage doing what they're great at and passionate about doing. Knowing that I had a part in returning them to that level of performance is very rewarding.

How long have you been using SportsWare?

I switched to SportsWareOnLine a few years ago when I started working directly for Boston Ballet. I needed electronic medical documentation and I originally went to a traditional physical therapy billing program. I didn’t find it very helpful in my environment, given that I don't have to bill insurance. I get paid directly by Boston Ballet to be part of the staff and take care of the dancers. I don't need to be Medicare compliant nor deal with a lot of the issues that follow traditional physical therapy documentation. An EMR that is more centered around athletic training is much more helpful for me. One of my colleagues who is the Director of Physical Therapy at Miami City Ballet introduced me to SportsWareOnLine. It has been extremely helpful because in dance medicine, and particularly at the professional level, we're trying hard to catch up to sports medicine. We need to be able to track injuries and see what happens from season to season and understand what causes the issues and look at patterns. All of the different databases and the ability run reports to look at trends in the injuries are incredibly helpful.

Can you tell me a little more about the reports you run?

I run multiple reports to look at injury trends and contributing factors, as well as what we have been doing for treatment. Even how many times we have physicians see the dancers on site. We are set up just the way any professional sports team would be managed. Since we have physicians that come in and see the dancers as well, it's very helpful to have the different aspects of the program. One part of the program that's been super helpful is the concussion assessment tool. Fortunately, we don't have concussions very often but when we do we take them very seriously. Given how many times women are lifted, one would think we would have issues with people being dropped more often. Sometimes even in stage combat the timing is miscalculated and someone actually gets a right hook to the face. So the concussion aspect of the program is really helpful. It also allows us to show the dancer there is no way they are prepared to turn, to be in lights, to balance, or do the things that they need to do above and beyond. We can really use some of the objective measurements in the system to clearly document what's happening, follow it, and see how long we have to keep someone resting and how they are responding.

How Does SportsWare impact your job?

It just makes everything a lot easier. Having the different databases is super helpful because it keeps things nicely organized depending on what you are dealing with. I also like the fact that we could be anywhere in the world and I can use it. Our companies tour and we're not always at a place where we have access to our information. Sometimes we are at the theater or studio. It's really helpful to be able to access it anywhere, whether it's on a phone, iPad, or computer.

The ability to dictate notes is helpful too. We write notes for almost every single encounter. Most days we're writing notes because things change constantly in our environment so the ability to dictate notes is very helpful. I will tap on the voice to text button on my phone. Siri doesn’t always get it right but it's so much faster.

SportsWare also lets me analyze what the costs would be if we had outside physical therapists see the dancers. I use the program as if I would be billing for services so I utilize the CPT codes. Having that ability is very effective when it comes to showing the Ballet cost savings. Last year it was around $600,000 in physical therapy billing for a 40-week season. That doesn’t include the potential injuries that have been avoided by our preventative care. It's helpful to be able to press a few buttons and come up with useful reports.

What are your favorite features about SportsWare?

I would say probably the reporting functionality. It's funny because I initially wanted to have an easier, more streamlined way of documenting, and keeping the kind of information that I need on a day-to-day basis. I feel like it aligns well with what physical therapists or athletic trainers in my position need. You can also customize a lot about it. Before I started using SportsWareOnLine, I was essentially making my own separate spreadsheets of information and counting through notes. We do something like 4,000 treatments a year in a 40-week season. There are probably 4,000 encounters so trying to do that by hand is impossible. SportsWare allows you to do that super easy just by connecting the right parameters. I really appreciate that and it has made a huge difference.

What has your experience been with customer service?

My experience with customer service and technical support has been phenomenal. I have used other electronic medical record programs. The customer service and technical support for SportsWareOnLine is way above anything else I've ever experienced. You generally can speak to the same person, every time. I don't have to explain that I'm a little technically challenged, Sue already knows that and she's very patient with me and says, "Let me help you through this." Even if I've asked her the same question five times, over maybe five months, she's great about continuing to help and being very patient. It is very user-friendly, but if you're not used to some of the functionality, it's so much easier to talk to someone and have them guide you through.

Are there any trends you're seeing in the industry?

Trend-wise, dance medicine is trying to catch up a little bit with some of the literature that's out there in sports medicine. And looking at injury tracking and how do we understand what's happening with injuries. With dancers, some of the injuries are similar to what happens in sports. For example, ACL, Achilles rupture, or an acetabular labral tear in the hip. But how they're managed can be very different. Some of the injuries are really very unique. I don't think other athletes sustain the same kind of flexor hallucis longus tendinitis and tenosynovitis that we see. Some of the ways things present are so different and it's nice to have programs like this where we can analyze what's going on. I think as more and more ballet and professional dance companies utilize this program, it's going to help us be able to do more for the industry so that we can really know what's happening with dancers, and how unique their injuries are.

For more information on the Boston Ballet, visit their website at www.bostonballet.org.