Course Notes: PRI Postural Visual Integration: The 2nd Viewing
Would You Look at That
It was a little over a year ago that I took PRI vision and was blown away. A little bit after that, I went through the PRIME program to become an alternating and reciprocal warrior.
I had learned so much about what they do in PRI vision that I was feeling somewhat okay with implementation.
Then my friends told me about the updates they made in this course.
I seriously just took it
I signed up as quickly as possibly, and am glad I did. This course has reached a near-perfect flow and the challenging material is much more digestible.
Don’t expect to know the what’s and how’s of Ron and Heidi’s operation. And realistically, you probably don’t need to.
Your job as a clinician is to take advantage of what the visual system can do, implement that into a movement program, and refer out as needed. This blog will try to explain the connection between these two systems.
If you want more of the nitty-gritty programming, I strongly recommend reading my first round with this course. Otherwise, you might be a little lost.
Let’s do it.
I See…
Vision is much more than just the ability to see clearly.
Although vision makes up 70% of the brain’s sensory information, only a portion deals with the picture perceived.
Visual input affects sensorimotor systems via connections to the superior colliculus. This brain area receives only peripheral vision. Thus, if minimal peripheral visual input is perceived, all sensorimotor systems must accommodate in some fashion.
That includes the movement system.
Most of us have these on and don’t even know it.
Due to parietal lobe asymmetry, there is a natural disadvantage to perceiving left space. Both lobes collect information from the right visual field, whereas the right parietal lobe is the only brain structure that maps left periphery.
Reproduced with forgiveness from a book I own
Combining the above two facts, it seems evident that a rightward visual bias can potentially influence how we move.
If peripheral space is decreased, the body will increase verticality to make up the difference. Vertical space increases as horizontal space decreases.
The need to extend becomes present as peripheral input is dropped off.
Eye Walking
“Gait is not owned by feet. It’s owned by processes of perception of all senses.” ~ Ron Hruska
Gait is a prime example of how the above paragraphs functionally work.
The gait cycle follows this typical progression:
Heel strike → midstance → push-off → early swing → late swing
A vicious cycle for some
This explains what occurs at the lower extremities quite simply, but rarely does one talk about what occurs at the thorax or visual system. These areas are also active in the gait cycle.
Gait is not just about legs moving, but systems locomoting.
Let’s take a more in-depth look at gait:
| Lower Extremity | Heel strike | Mid-stance | Push-off |
| Thorax | Weight acceptance | Trunk glide | Push to balance assist |
| Vision | Peripheral contact | Peripheral Optic flow | Peripheral propulsion |
Peripheral contact…
is simultaneous awareness of the floor and peripheral vision. Lacking peripheral vision will increase difficulty finding floor and reaching out into space with the stance side arm.
Limbs will not interact with unperceived space.
Peripheral vision is important folks
This process can be improved by perceiving peripheral objects without directly looking at them, judging distances between objects, and progressing from enclosed environments (e.g. hallways) to open environments.
“Your heel is a strike bone. If it doesn’t your visual system will strike hard.”
Peripheral optic flow…
is sensing objects moving backward as the body progresses forward. This sensory input provides space for a body to propel into, and is needed for centering during midstance (more on that later).
To enhance this quality, one can notice objects in periphery moving backward, tap objects with the left hand, and tap ground with the right foot.
Adam Sandler may be the best Optometrist you know.
Peripheral propulsion…
is noticing the body moving forward through space via alternating peripheral awareness. In order to notice this change, one must become aware of arm swing occurrence.
Recognizing arm swing is what allows the contralateral lower extremity to swing forward and “catch” the advancing body weight. Lacking this quality may be why many individuals have poor arm swing during the gait cycle.
“Feet don’t swing unless arms swing” ~ Ron Hruska
So to summarize this progression, one must recognize peripheral space to contact ground (peripheral contact), ands notice objects in the periphery passing by (peripheral optic flow) as the body progresses forwardly via limb reaching (peripheral propulsion).
If these pieces are not present in gait, then forward progression may not occur with integrity. Namely, because there is no perceived space to move through nor is there ground to contact. Lacking these inputs creates increased verticality (i.e. extension) in order to prevent falling, which is ultimately what makes the PRI patterns (dis)advantageous.
Centering
In order to effectively master midstance, one must be able to center.
Centering is the ability to balance ascending (foot and ground support) input while perceiving appropriate visual input in a lateralized, upright position.
If one cannot center, the visual system can possibly enhance focus on a close or far object to stabilize the body upright. This enhanced focus will likely promote system extension by dropping off peripheral vision. As we learned above, dropping off peripheral will impact one’s ability to manage the floor and reach with extremities.
Here is what it looks like:
Having the ability to center is what connects space, ground, and body for effective ambulation.
An Optometrist’s Role
An optometrist elicits postural change by manipulating space with lenses. This orthotic works by:
- Changing where the extraocular muscles are directed.
- Altering visual information received both consciously and subconsciously.
- Affecting clarity.
These changes can remove undesired references or enhance desirable ones; especially if other sensory inputs have failed.
Lenses alone will not make a favorable change; one must implement a movement-based approach to use the references a lens may allow access to.
Lenses are akin to manual therapy; creating a window for movement to drive neuroplastic change.
Realize that regular optometrists won’t be able to do the things that one who is PRI-trained will. A traditional or even neuro-optometrist is not looking at vision as an extension of a triplanar system.
That said, that doesn’t mean that a traditional neuro-optometrist isn’t essential to have. Sometimes keeping the eyes working together (binocular vision) without being overcorrected can do wonders.
Some suggestions for your local OD could be asking for power less than 20/20; or putting someone in distance-only glasses over bifocals or progressives. These lens types are not inherently bad, but some individuals may not use them properly; especially if there is no clear delineation between lenses.
For some this could be proper use #ohsorrywrongcourse
Another suggestion may be to try the spherical equivalent, which basically eliminates the patient’s astigmatism correction.
Here are a few examples of people who you may want to send to an optometrist:
- People who can’t drive at night due to vision – these folks use the visual system to stabilize.
- People who have some type of visual impairment, cataracts as an example.
- People who are near sighted. These individuals may not pay attention to distant or ambient information because it’s imperceptible.
- Monovision – get them out of this!
A lot of optometrists may use vision therapy to aid in the process, and this modality can be extremely beneficial. However, it is imperative that the neck is neutral prior to going this route. Teaching visual skills on a locked-up neck can keep the neck patterned.
Visual Coaching
Ron and Heidi provided some excellent coaching tips that I thought needed to be shared.
On references centers…
Clients attending to and feeling reference centers is essential, but they can’t overfocus on trying to feel only one reference. This may lead to increased system focus, which is associated with extension.
Or worse yet, right lateralized hair styles.
On speed…
Speed is not the name of the game during PRI vision programming, as greater pushes in speed lead to greater extension demands.
On Neurodevelopment…
For those into using neurodevelopmental techniques, reaching capability precedes creeping and crawling. The reach must be taught first before the latter skills are applied.
If you don’t have a neutral thorax, you lack the ability to crawl.
Infamous Ron Quotes
- “I don’t know if there is such a thing as running anymore.”
- “I see biceps, lats, and pecs, oh my.”
- “[Running] is the best horror movie you can go to.”
- “In every shoe store there should be an optometrist.”
- “I have glasses on ankles and I have shoes on eyes.”
- “Animated hands are alive people.”
- “Hips are the glue between floor and space.”
- “Your hand is your communicator of your body.”
- “Chairs ruin squats.”
- “I want saccadic ankles.”
- “Pronation is periphery.”
- “Gait is probably better owned by your visual system than the floor.”
- “We see people who push off and want to get to the moon.”
- “Feet don’t swing unless arms swing.”
- “Balance and cognition are the same thing.”
Very Wise Heidi Quotes
- “Neck, vision, and vestibular are all locked together.”
- “My job is not to make you see clearly.”
- “Sometimes pain is a good reason to give up convenience.”
- “Just because you see doesn’t mean you use it.”
- “People tell eyes what to look for.”
- “You won’t reach if you don’t see space to reach into.”
- “You won’t change if you see the world as you do.”
- “When patients pick up speed during a program, you are done.”
So during the rehab process, please resist feeling the need.
Course Notes: The Val Nasedkin Seminar
A Long Lost Love
Strength and conditioning is a guilty pleasure of mine. One I love to indulge in from time to time.
There is something about the training process that excites me. So when I heard Val Nasedkin was speaking in the US, I jumped on the opportunity.
Kemosabi-style of course
Val is the brilliant mind behind the Omegawave, a device which I have been experimenting with in my own training and hoped to learn more about.
I left with a greater appreciation not only for what Val’s system intends to do, but the way he coaches and programs.
If you get a chance to hear Val or Roman Fomin speak, take up the opportunity. These guys are both revolutionaries in their respective fields.
Here were a few of the big takeaways.
Ze Goal
Val created the Omegawave to provide a framework and determine appropriate timing for our current performance methodologies.
Most training and rehabilitation processes are chosen based on results. focusing here, however, neglects individual responses to inputs.
Great results can come at a great cost to an individual.
If biological cost of training can be measured, there is potential to maximize an individual’s health, long term potential, and work capacity, while still achieving desired results.
That is what an Omegawave can do for you.
“Ask not what you can do for Omegawave, but what can Omegawave do for you” ~John F. Kennedy
The Performance Matrix
Whether Val knew it or not, he drew many parallels to Melzack’s neuromatrix regarding how performance occurs. I lo Like this profound statement…
“Every process [output] occurs for a good reason.” ~Val Nasedkin
Our expressions and behaviors insure our survival at a minimum, and performance at a maximum.
Specific outputs depend on feedback received by the body’s regulatory systems (i.e. nervous system). Positive feedback will lead to high performance, negative feedback will lead to compensatory strategies that help an individual survive.
A negative feedback example – Reduced ATP production by the aerobic system will shift energy production to less efficient glycolytic mechanisms.
A positive feedback example – Aerobic training done properly will lead to increased mitochondrial density, which will lead to higher performance for particular tasks.
My mitochondria has brought me to you
Functional State
The functional state is what Omegawave is attempting to measure via CNS, ANS, and cardiovascular measures. It’s defined as…
-The physiological foundation for future activity.
The functional state reflects the body’s functional systems at a given period of time. This state changes based on inputs the system receives.
The hope, with good training, is to take nonspecifically working systems and create specifically coordinated adaptations to best perform a task. Measuring functional states helps pick desirable times to train said adaptations.
Changing a specified functional system must be done carefully. Making a change, even if potentially favorable, can negatively impact performance to the point where positive adaptation may take too long to occur.
You wouldn’t attempt to change a sprinter’s mechanics during an Olympic year.
As funky as his form is, he sure is fast!
Success’ Components
Per Val, there are certain general adaptations found in all successful athletes. Generally these adaptations include favorable hormonal adaptations, aerobically developed cardiopulmonary and neuromuscular systems, parasympathetic activity, and CNS activity/synchronicity.
The aforementioned qualities are desirable because they have the largest room to improve. Other adaptations, such as speed and power, top out at a much faster rate.
Val mentioned several methods to create these adaptations. Here were my favorite ones (Joel Jamison’s book is a great further read for these qualities):
Resistance training for hormonal adaptations
- Need to create a hypoxic environment
- Max effort resistance to total failure within 4-8 rep range
- 2 times per week; one hard day, one with 50% volume of previous hard day.
Stato-dynamic resistance training
The goal is slow twitch muscle fiber hypertrophy and mitochondrial hyperplasia via a hypoxic environment. This sounds counterintuitive because hypoxic environments destroy mitochondria. However, slow twitch fibers naturally have large mitochondria amounts. Since hypoxic environments increase muscle size, larger slow twitch fibers would increase mitochondrial density.
How it’s done:
- 30-50% 1-RM with slow velocity and no rest periods (don’t lock into joint extension)
- Use big muscle group exercises
- 40-60 seconds work:rest ratios for 4-5 rounds.
- 2 times per week.
- Done to screaming in pain failure, but should be able to breathe.
Here’s a video of this courtesy of Mark McLaughlin, another cat you should probably check out:
High Intensity Continuous Training
The goal here is to increase mitochondria density in fast twitch muscle fibers. Since type II fibers are not normally mitochondria-rich, hypoxic environments are undesirable.
Here’s how you do it to increase myofibril oxidative capacity:
- 20-40 minutes of low frequency, high to max resistance
My good friend Lance Goyke demonstrates this below:
If oxidation is needed in the sarcoplasmic reticulum, use plyometrics or resisted short sprints.
- <5 seconds at high intensity, recovery to 100 bpm or so
- Very high volume
Once these general qualities are achieved, more sport specific components can be targeted.
Planning
Putting all these components in a week can seem daunting, but applying a few smart rules can maximize training adaptations.
The overall theme is to have few high intensity/volume days, and several low intensity/volume days.
At most, there ought to be only two high intensity sessions per week, with the second one having lower volume. These sessions ought to focus on an individual’s biological limiting factors.
The above may have some conflicts with traditional periodization; namely focusing on biological limiting factors. For example, I ran collegiately, and every off-season involved aerobic base work. This training aims to increase cardiac output. For some individuals, those adaptations may already be present after a certain amount of training. Therefore, the “base” phase may not be necessary for some. That is why measuring several biomarkers (and the Omegawave fits here) may indicate which sessions ought to be best.
If the above sessions involve creating hypoxic environments, following sessions should emphasize aerobic development. First destroy mitochondria, and then use aerobic exercise to manage the damage.
A sample offseason week may look like this:
| Monday | Tuesday | Wednesday | Thursday | Friday | Saturday | Sunday |
| High intensity | Low intensity | Low intensity | Low intensity | High intensity | Low intensity | Off |
| High Volume | High Volume | Moderate Volume | Low Volume | Moderate Volume | Moderate Volume |
The rules change if competition is in the mix. The main difference is timing your high intensity sessions. Depending on the intensity of the competition, the high intensity and volume sessions may be very early in the week, or even considered the competitive day.
For example, a high jumper that performs on Saturday may have his high intensity/volume day on Monday. Whereas a basketball player may have his Saturday game be considered the high intensity/volume day. Everything depends on the individual athlete.
And if you wear depends.
Individualized templates will produce the best outcomes.
Training Kids
This portion may have been my favorite lecture. Val was very much against heavy weight lifting for children. Because children are undergoing several hormonal changes, high intensity resistance training may have unforeseen effects on one’s endocrine system. This training becomes more appropriate post-puberty.
Instead, take advantageous of a child’s rich nervous system. Teach basic movement patterns, calisthenics, plyometrics, speed, shock training, quickness; anything that requires high neural drive. Create fundamental movement patterns that individuals will be able to take with them once more advanced methods can be applied.
Weekend Quotes (courtesy of Val, Roman, Charlie Weingroff, and Sam Gibbs)
- “How important is sensory-motor? I don’t care.”
- “They have like bullheart…It’s a term.”
- “Stretching is borderline absurd.”
- “Guiding by results does not lead to long term change.”
- “It’s not what you do, it’s when you do it.”
- “Yes, you can kill yourself once a week.”
- “Can’t use linear methods to solve nonlinear problems.”
- “You can’t squat heavy with poor ground contact.”
- “If you can’t change what other people do, change what you do.”
They have bull heart, and I have bullshit. And that’s the difference folks.
Course Notes: Cantrell’s Impingement and Instability, 2015 Edition
Third Time’s a Charm
A trip home and hearing Mike Cantrell preach the good PRI word? I was sold.
The power of the ultimate orthotic compels you
Impingement and Instability is one of those courses that I could take yearly and still get so many gems. In fact, I probably will end up taking it yearly—it’s that good.
I took I&I last year with Cantrell (and the year before that with James), and the IFAST rendition was a completely different course.
Cantrell provided the most PRI clinical applications I have seen at any course, which is why he continues to be one of my favorite people to learn from.
Basically, if you haven’t learned from Mike yet, I pity you. Get to it!
And especially missing it with this group. Come on people!
I have way too many gems in my notes to discuss, so here are a few big takeaways.
I Sense a Disturbance in the Force
This course focuses on esthesia, namely sensing and feeling particular body-spatial areas. More specifically, reference centers.
Referenced areas occur as a reaction to the environment. In certain environments (e.g. stressful, threatening, painful), we will tend to reference certain body-spatial regions compared to others. The norm is to extend in order to combat gravity. Continual threatening inputs will perpetuate a LAIC/RBC/RTMCC/PEC.
The above pattern will occur to increase oxygenation and reduce dyspnea. Airflow is priority number one, and the neuromuscular system has damn efficient ways of maximizing this.
It’s evidenced based
The clinical goal is to provide alternate references via learnable nonmanual activities until habitual movement strategies manifests. Until movement variability is maximized and we can achieve any desired joint position.
The ZOA is the Real
PRI folks, myself included, love getting caught up in the cool vision, dental, and auditory components. But the most underrated treatment piece is a zone of apposition.
This natural orthotic is often forgotten, and greatly underappreciated. True ZOA acquisition likely eliminates unnecessary interdisciplinary integration.
Can’t get a person neutral? ZOA.
Can’t get someone to feel a muscle? ZOA.
Yes…the answer is still ZOA
Revisit the foundation often throughout treatment; as dyspnea becomes more prominent with progressing nonmanual techniques.
HALT Right There
Passive movement variability and neutrality merely demonstrates unstable potential. The HALT answers if one can manage that instability.
If one has a higher right HALT compared to the left, it’s probably fake. What is likely occurring is the right adductor is overpowering that individual up despite reduced left abdominal integration.
Said every time I see that 2 on the left HALT
Focus on left abs in these instances. Mike was a huge fan of plank/trunk lift variations to build this awareness. Playing with these activities this past week has made my patient’s HALT scores change quite dramatically. These activities are integral in bringing someone from a 2 to a 3. Here are my two current favorites
Brachial Chain Cleanup
I’ve been sorely mistaken on the bilateral BC.
Since it’s been awhile
In the RBC pattern, the left ribcage is externally rotated and the right internally rotated. This creates the ribcage leftward counter-rotation from right spinal orientation.
In the BBC, the ribcage position is the same.
What creates the BBC is increased left pec activity to the point where the left scapula becomes protracted similarly to the right side. This positioning creates the often seen left internal rotation deficit.
The right rib cage cannot externally rotate because of right intercostal hyperactivity via the RBC. What can happen is ribs 8-10 may start to externally rotate by ZOA loss. This change is your classic inferior T8 syndrome.
Mad love for Subscaps
An often neglected muscle is the subscapularis. It does some cool stuff:
- Inhibits a lat by re-teaching HG internal rotation
- Provides muscular support for a possible SLAP tear (HG IR >80 degrees when other BC tests are positive)
If you have someone who keeps losing BC positioning, still has symptoms, or is at the end stage of programming, go after this guy.
Here is a nice little way of integrating a subscapularis into any activity:
And my current favorite to get a subscap on either side.
Cantrell the Cue Monster
Cantrell is an outstanding coach. One of the big cues he gave for the weekend was incredibly simple yet worked so damn well.
In many exercises and activities, one often cues pressing down into a table or pulling a band down to engage the core.
What can sometimes be problematic with this cue is rectus abdominis and lat overactivity. A simple fix? Flip the resistance direction
Cantrellisms
- “Without movement variability life sucks.”
- “While you’re doing symptom management it would be nice if you treat the problem.”
- “Parlor tricks are slop unless you know why the magic works.”
- “Hanging by your lat does not fix anything.”
- “If you can’t suck, you suck.”
Maybe not
Course Notes: Explaining Pain Lorimer Moseley-Style
Why Weren’t you Here??!?!?!?!?!
A late addition to the yearly course list, but a decision I will never regret.
Regret? You serious?
Lorimer Moseley is one of my heroes in the pain science realm and I’ve always wanted to hear him speak. His teaching style—slow paced, humorous, filled with story, and unforgettable—really resonated with me and made his material so easy to understand.
My admiration for him tremendously grew because he was readily admitting if he didn’t know something, critical of his own body of work, and very open to what we we do clinically. I got the impression that he was okay with us practicing how we wish, as long as our treatments are science-informed and coupled with an accurate biological understanding.
I left the talk validated, reinvigorated, and better adept at educating patients. He put on one of the best courses I have been to. If you haven’t seen Moseley live or had the chance to interact with him, please do so.
Let’s go over the big moments.
Big moments with a big group
Sensitization 101
There are three sensitization types:
- Peripheral
- Spinal (formerly central sensitization)
- Central Sensitization
Let’s break down each.
Break it down
Peripheral Sensitization
Peripheral sensitization (PS) occurs when primary nociceptors become sensitized. When these nerves fire, they send a danger signal up to the spinal cord in one direction, and release substance P and CGRP in the other direction. The distal discharge equates to neurogenic inflammation.
Primary nociceptors can become sensitized by inputs from the sympathetic nervous system, endocrine system, and immune system.
Adrenosensitivity was a big discussion point this weekend, as it can occur incredibly quickly. When adrenaline is present in the extracellular matrix, adrenoceptors can form in the nerve’s cell wall. We are not exactly sure as to what causes this shift. Not even pain can be implicated. However, genetics do play a role.
Always plays a role, doesn’t it?
Primary nociceptors are sensitive to heat, hydrogen, and mechanical stimuli, so one can diagnose peripheral sensitization via a hot pack.
Spinal Sensitization
Spinal sensitization (SS) is when the spinal nociceptor becomes sensitive. This change was originally called central sensitization, but the literature no longer thinks of this change as such.
Although primary nociceptors can be affected by multiple systems, spinal nociceptors can be sensitized by the immune system only. This is how mirror pains, when a similar pain is produced on the contralateral side, can be created by an immune reaction.
No doubt JT gets an immune response seeing his old hair style.
Spinal sensitization only responds to mechanical stimuli, so if a hot pack has no effect you can likely go this direction.
Spinal sensitization can occur without peripheral sensitization. The reverse can only be true for about 30 minutes.
Central Sensitization
Central sensitization (CS) is both increased sensitivity to peripheral input reception and descending facilitation production. Theoretically, any input deemed threatening could be received more readily in this state.
“Threats hide in hard-to-spot places.” ~Lorimer Moseley
Cortical facilitation of relevant neurotags occurs via the following mechanisms:
- Brain cells become more easily recruited
- Brain cells stay active by inflammatory response.
- Adjacent brain cells become active.
- Sensitivity of multiple neurotags occurs.
An Order That Would Surprise You
If you get it +5
Sensitization, at least to a needle, occurs in the following order
Spontaneous pain for 1-2 minutes (primary nociceptors) → heat sensitivity for 1-2 hours (PS) → dynamic tactile allodynia for 3-4 hours (SS)→ pinprick hyperalgesia for 24 hours (SS)
Then, in a 3-24 hour time period afterwards the contralateral side develops sensitivity—a mirror pain.
Protection System
Sometimes dangerous inputs can lead the brain to produce protective outputs. Pain is one of those possible outputs; a conscious output that can lead to desirable protective behaviors in the short term.
Pain is just one protective system. The system(s) that respond are idiosyncratic. These responses can continually occur, and it becomes harder to produce other outputs when the brain gets so good at playing protective ones. This static replay is a loss of variability, and the longer outputs occur the longer it will take one to recover.
Which is why it took me two weeks to get this flipping song out of my head, and I’m not even sure why.
Playing these protective outputs can potentially lead to other problems as well. Take the motor system for example. If a protective motor state is present, secondary problems may arise at other body systems or even other body regions. It’s not that patterns cause pain, but that they leave an individual vulnerable. Hearing this from Moseley was quite validating.
“The strongest neurotags win.” ~ Lorimer Moseley
As great as a threat pain can be, outputs such as fear, thirst, and hunger will usually trump pain. These outputs occur in response to threats greater than potential tissue damage. Comparing pain to these outputs can be enlightening for patients.
Explaining this Stuff
What can be most challenging is explaining pain to patients, but we must give our patients all the possible resources to make the right decisions. Lorimer suggested this occur by the following process:
Challenge a concept → provide an alternative concept → Provide evidence for a new concept
The big concepts we want to hit with our patients include:
- Understand pain does not equal injury.
- Dethreaten MRIs
- Dethreaten the patient’s model.
- Provide control.
- Teach safe movements
- Graded exposure.
Lorimer is big on stories and analogies. I’m sure many of you have heard his stories, but he provided great tidbits to give to patients.
I See
Explaining how vision is analogous to pain is a great way to challenge the concept.
Vision works by light hitting the retina upside-down and brain is able to flip the image so the world appears as it does. However, vision doesn’t always match reality. Take this visual illusion for example.
If you are like most people, you will see a distinct color difference between each block. However, if you put your finger over the border between the blocks you will see they are the same shade. This illusion illustrates how the brain takes a guess at what we are looking at based on many factors, and sometimes it can guess wrong.
Pain works in much of the same fashion. Pain will correct any error it sees from spinal cord inputs via descending inhibition or facilitation.
As vision is our window to the environment, pain is our window to protection. Sometimes that window can be unclear.
Broken Bones
Pain stops way before a broken bone heals; usually by the time you’re casted. Why?
The need to protect is lost because the cast acts as our protection device, not pain. This analogy is a great way to show patients how pain and tissue healing do not always correlate.
Prized Possessions
The most vulnerable areas (i.e. brain, spinal cord, pelvis) are reinforced by strong structures covered in nociceptors, like a safe that houses prized possession. This is a built in security system that your body has to protect the goods you possess. Wouldn’t it make sense that anything remotely dangerous happening in that area might set off the alarm cascade?
Watch your patient melt with that explanation.
Actual footage of me from the first time I took Explain Pain.
What Do You Mean by that?
We’ve all had the patient that lists everything medically wrong with them that their doctor told them regarding their pain.
You ever ask them “what do you mean by that?”
You will be amazed at the answers you get. Arthritis is the prime example. A woman I saw the other day mentioned that the doctor said she had arthritis, and I asked her what that meant to her. Her response was classic:
“I’m not really sure” ~My patient
Unveiling concepts that are unclear to patients can be a huge way to dethreaten scary medical terminology, and turn them around into nonthreatening knowledge nuggets.
Thankfully doctors don’t always explain things well.
My life…every…damn….day
Betta Meta’s
How do you guys like the phrases “my bad back” or “my pinky is killing me?” These verbal bits could potentially be components of a threatening neurotag. Keep saying it, and the neurotag persists.
We want to do whatever possible to cease usage of these metaphors. The “bad x” can be dethreatened by clarifying what they mean by that. I like telling patients that their back is so strong that it is putting all the work in to protect them.
The “x is killing me” bit? Getting the patients to realize that the body part is a part of them, and even teaching about the neurotag, can be a great way of stopping this metaphor.
Let’s Emote
Bringing emotion into the mix will help patients learn better. That way individuals can associate a feeling with a concept. I like humor, as does Lorimer. But even sadness, fear, anything can work.
Just pick emotions that an individual will not perseverate on.
Chalk up Your Cues
Lorimer mentioned a study where dentists performing wisdom teeth extraction were told that they were giving placebo pain medication; when in actuality 50% of them were giving actual medicine. They compared this group to a 50-50 split group.
The results?
Even though the practitioners were still blinded, those patients who received the injection from the former group had significantly higher pain levels than those patients who were a part of the latter group.
Yeah, I feel the same way Dave
How is this possible? The answer is in the subtle cues that the practitioners provided. It is these cues that can change the course of a patient encounter.
“We are more compelling if we believe what we believe may work.” ~Lorimer Moseley
Cues beget us to pay greater detail to our patient interactions. Lorimer “got me” on this once was when he was EP’ing me.
Lorimer: “I understand that you injured a tissue and it hurts a lot right?”
Zac: [Nods head fully engaged]
I was like Lorimer’s bobblehead. And yes my shirt was off.
For sale soon at zaccupples.com?
He had me at the nod. When you see an individual nod that shows that you got them, and that is the prime time to start injecting dethreatening knowledge. Whatever words were used to acquire the nod ought to be continually used. These are positive inputs to create positive behavior, and will keep patients agreeable with your education.
Other interesting ways to create evidence-based patient buy-in include:
- Dressing as attractively as possible.
- Having visible expensive car keys.
- Using an extensive vocabulary.
- Nodding when you want the patient to nod.
Staying fly is evidence-based.
Quotes
- “I’d like to apologize for the last remnants of snot in my nose.”
- “When you do research it’s impossible to remove bias.”
- “Placebo is what we call things we don’t understand.”
- “We can do some neck mobilizations if you’d like. I just need someone else to teach it.”
- “If you load someone up on NSAIDS and steroids and shoot a gun behind them they won’t forget it.”
- “Research doesn’t match the real world.”
- “We are fearfully and wonderfully complex.”
- “Pain does not exist until the brain plays the pain tune.”
- “It’s not the brain that does it, it’s the human that does it.”
- “We insert ourselves into the brain of everyone we treat.”
- “Pain is behaving like any other conscious experience.”
- “Pain is a protector, not an informer.”
- “If you can reposition them and they’re pain-free. Perfect.”
- “I believe graded exposure will save 99% of the world’s problems.”
- “There is no pain threshold. We have a protection threshold.”
- “Graded exposure is slowly throwing threats into the bucket without creating a protective response.”
One of the greatest games of all time. One of the greatest presenters of all time. Period.
Manual Therapy Musings
When I think About You…
Prompted by some mentee questions and blog comments, I wondered where manual therapy fits in the rehab process.
To satisfy my curiosity, I calculated how much time I spend performing manual interventions. Looking at last month’s patient numbers to acquire data, I found these numbers based on billing one patient every 45 minutes (subtracting out evals and reassessments):
- Nonmanual (including exercise and education) = 80%
- Manual = 20%
- Modalities = 0%!!!!!!!!!!!!
Especially happy with the last number…and that I forgot how to work these useless things.
Delving a bit further, here’s my time spent using PRI manual techniques versus my other manual therapy skill-set:
- PRI manual = 14%
- Other manual = 6%
As you can see, I use manual therapy a ridiculously low amount; skills that I used to employ liberally with decent success.
Greatest skits on the internet per Cochrane review.
There’s a reason for the shift
I want my patients to independently improve at all cost and as quickly as possible. The learning process is the critical piece needed to create necessary neuroplastic change; and consequently a successful rehab program.
Rarely is learning involved in manual therapy.
Manual therapy at most should provide a salient stimulus that facilitates a positive learning environment for that individual.
You could stop reading there…but plz don’t
Despite my minimalist manual approach, I think it is still important to have a vast skill-set to skin the proverbial cat. The more novel inputs one can provide, the more likely many patients will enter that aforementioned learning environment.
Here’s how I select what I am using.
So I’m Kinda Biased
Before we dig into what I like to use, here are a couple biases I am going to make:
#1 All manual techniques likely work under a similar mechanism.
Under the right context and for the right individual, every technique works. You are not breaking up scar tissue, deforming fascia, and all this other hullabaloo.
Remember, its about providing a salient stimulus that coaxes the nervous system into creating a favorable novel learning environment.
#2 Patient preference trumps everything
This reason is why you might need a “toolbox”. One technique is not going to work for everyone. Some patients may prefer certain types of touch compared to others.
Some people want you to be gentle, some dig stretching.
Believe it or not, some people want manual therapy that is uncomfortable.
I beat the tissue up, up, up, up, up, up, up.
Whatever the patient wants, insofar that it meets your mutual goals, is what ought to be done.
What are those goals?
Goals? I’m Glad you Asked
From here on out, let’s assume the patient has no intervention preference. Here are my goals with my manual interventions.
#1 – Can it change my PRI tests?
You can have a toolbox that Tim Taylor would envy, but you will be unsuccessful if you lack a systematic approach. You can’t always expect to hit a bull’s-eye randomly throwing darts at the neural dartboard.
Who knew you could actually buy a neural dartboard? Might be my new gift for unsystematic clinicians.
A system provides an objective end-game to which your manual interventions ought to change. It doesn’t rely on patient perception, which can often be clinically misleading and send you on a pain scavenger hunt.
My system is PRI, and my primary goal with that system is to restore movement variability. I’ll define that as active and passive mobility in three planes. You can use whatever system you like, just have something.
#2 – Can it ameliorate the patient’s symptoms?
If pain remains after a patient’s movement variability is restored, you might need a symptom-reducing input. Pain does impact motor control, and a well-planned manual intervention followed by movement can have quite the positive impact.
Other Considerations
Preference, objective measures, and patient perception take top priority. However, there are a few other important qualities to consider when selecting a manual technique:
- Speed – The less time I have to spend doing a technique the better. Speed allots patients more time to learn a movement or concept.
- Comfort – I will generally perform the most comfortable intervention possible. Throwing pain in the mix runs the risk of increasing threat perception.
- Skill level – I usually pick stuff I am good at. You ought to do the same.
You play to your strengths, pal. That’s all any of us can do. I’m mysterious, I’m, you know, good at coaching and you’re…you are a…uh, you know, stable employed physio.
The Brand Names
I have accumulated many manual skills over the years. There are certain body regions that I find certain techniques more effective than not, but In general my hierarchy goes like so.
Bottom is most frequent, top is least frequent.
This pyramid is subject to change.
Let’s dive a little deeper if you are unfamiliar with each. I’ll rate the following qualities:
- Movement Variability
- Symptom relief
- Speed
- Comfort level
- Best body regions
Here’s the grading scale, from least to most effective:
Least effective Most effective
Hella lame ⇔ Yuck ⇔ meh⇔ mmk⇔ Nice!⇔ Hellz Ya⇔ Daaaaaaaamn
Daaaaamn is to be said as such if reading aloud.
Let’s break it down
PRI Manual
- Movement Variability: Daaaaaaaamn
- Symptom relief: Daaaaaaaamn
- Speed: mmk
- Comfort level: meh
- Best uses: First line of defense, thorax, neck, cranium, hips
Obviously quite biased toward these techniques. These are hands down the best at improving variability; especially because they have a motor learning component. The only downside is the discomfort that comes with playing on ribcages. Sometimes you can feel like you are suffocating during. But because it’s most often not the problem area, my patients generally like it.
Learn it here.
Pin & Stretch
- Movement Variability: mmk
- Symptom relief: Hellz Ya
- Speed: Hellz Ya
- Comfort level: mmk
- Best uses: Hip, shoulder, spine, neural tracts
Have not had formal training, so I can’t say what it’s based off of (hint, it rhymes with K-mart spree). Basically, take up tension, and move through that tension. I have modified my contact over the years to make this technique as comfortable as possible; adjusting if my patients perceive any pain.
Unfortunately, you can’t say great prices regarding the un-named manual course.
Dermoneuromodulation (DNM)
- Movement Variability: Yuck
- Symptom relief: Hellz Ya
- Speed: meh
- Comfort level: Daaaaaaaamn
- Best uses: post-op, extremities
I’ve taken quite a liking to Diane Jacobs’ technique because it is quite comfortable. I use it most often after I’ve maximized one’s movement variability and if symptoms remain. I find it a nice finisher to most sessions.
Learn it here.
Mulligan
- Movement Variability: mmk
- Symptom relief: Hellz Ya
- Speed: Nice!
- Comfort level: Daaaaaaaamn
- Best uses: Neck, elbow, knee
Have not had formal training, but my musculoskeletal professor in PT school was a big fan and taught us a lot. Basically, Mulligan boils down to changing the context at an area, then having the patient move within that context. I love Mulligan because it’s fast, painless, and has a learning component to it. You can also take these techniques home with you. Winner for me on many levels.
Learn more here.
Mulligan is the cream on the milk. If you can find his older edition books you’ll get a good chortle.
Static Manual Contact
- Movement Variability: Nice!
- Symptom relief: Nice!
- Speed: Yuck
- Comfort level: mmk
- Best uses: Post-operative stiffness, frozen anything
I use this style on my peeps who have shoulder surgery. I find that combining low load long duration with gentle manual contact to be quite an effective way to explore movement when passive restrictions hold the patient back. My contact usually goes over muscle areas that make sense. For example, if someone is limited in external rotation, I’m touching the subscapularis region. You can also throw neural flossing into the mix. It’s quite versatile; just takes a while.
Sensory Discrimination
- Movement Variability: Hella lame
- Symptom relief: Nice!
- Speed: Meh to nice!
- Comfort level: Hellz ya
- Best uses: chronic pain, post-operative sensitivity
I’ve been using this stuff a lot more since I read Adriaan Louw’s CRPS book, and this stuff works. I like it quite a bit because it keeps the patient active in treatment. It’s almost meditative. Great things happen with this post-operatively.
Primal Reflex Release Technique (PRRT)
- Movement Variability: mmk
- Symptom relief: mmk
- Speed: Daaaaaaaamn
- Comfort level: Daaaaaaaamn
- Best uses: craniocervical region, shoulder
PRRT is a crapshoot for me. When it works you will dazzle your patients; when it doesn’t you will look like an ass hat. It can have profound mobility effects on the entire body, and probably works best with RTMCC people who may not need integration. Sadly the effects don’t last super long. At least it only takes seconds to perform.
Learn it here.
I wear one pre-emptively during PRRT just in case
Joint Mobs
- Movement Variability: Yuck
- Symptom relief: meh
- Speed: mmk
- Comfort level: Nice!
- Best uses: Hips, knee (especially post-op), ankle
Maitland was God in PT school, but I just haven’t found this stuff to be super effective. It might be a nice homuncular refreshment for certain people, but I wouldn’t expect miracles. And for the love of David Butler stop worrying about grades. You’re not affecting tissue properties.
Instrument Assisted Soft-tissue Mobilization (IASTM)
- Movement Variability: Hella lame
- Symptom relief: mmk
- Speed: mmk
- Comfort level: Nice!
- Best uses: edema reduction, post-operative
I don’t use this jazz too often, as I feel there is probably a better social-grooming/neural component when there is actual physical contact between people. That said, it’s a novel stimulus that occasionally works. Please don’t bruise people and don’t make it hurt. Pick whatever tool is cheapest; doubt there is much difference among them all.
I learned it from Dr. E.
Manipulations
- Movement Variability: mmk
- Symptom relief: Nice!
- Speed: Hellz Ya
- Comfort level: meh
- Best uses: feet, neck pain, ankle sprains
“When in doubt, manip it out” was the mantra in my residency, but it has fallen out of favor with me over the years. There are just many less threatening techniques that work just as well. I will say this though; thrust manips on the feet work wonders.
From what I’ve heard, the most gentle of the bunch is through Gibbons and Tehan. I am also curious about SMI‘s extremity offerings.
Just make sure you have the hands for it.
Dry Needling
- Movement Variability: ???????
- Symptom relief: ????????
- Speed: ?????
- Comfort level: Hella lame
- Best body regions: ?????????
I haven’t really figured out where this sits for me yet, so I’ll reserve judgment right now. None of my patients have been needled yet, and the folks who I think it may help have needle-phobias. Perhaps if I update this a year from now we will have some answers.
Take it through SMI.
The Last Word
These techniques make up my 20%. As long as you respect patient preference, maximize movement variability, and have patient independence on the mind, you are doing the right thing.
You don’t have to pick the stuff I use. The best advice I can give when learning manual interventions is to pick skills that you feel you can perform well, and use them as an adjunct to a non manual-dominant program.
Thoughts or comments? What manual interventions do you use? Where does manual work fit for you? Comment below.
