A Fly on the Wall of the Hruska Clinic

The Saga Continues

 This post is way over due, but a lot has been going on in life.

I have just moved to Arizona to start anew, and the change is bittersweet.

The Midwest is all that I have known for the past 27 years. I’m leaving a lot of loved ones behind that I will miss dearly.

However, getting out of the Midwest to a warmer place has always been a dream for me, and I finally got that opportunity. I also get to work at an awesome clinic alongside like-minded clinicians. One of my good friends will even be there.

This is how I envision day one of Young Matt and I in the same clinic.
This is how I envision day one of Young Matt and I in the same clinic.

Plus, summer forevaaaaaaaaaaaahhhhh!!!!!!

So with this transition in my life marks a good time to reflect on one of my many experiences at the Hruska Clinic. This time, I will show you how the clinic itself operates.

And their operation is a beautiful thing.

I was at a clinic once, and it was beautiful, like you.
I was at a clinic once, and it was beautiful, like you.

The General Feel

You walk in the door and can immediately shift into your left hip.

That’s what this place is like upon entering. With various shades of purple and tan, you just feel at ease being there.

It screams parasympathetic.

This build was no accident of course. Purple is a calming color, giving those at the clinic a huge home-field advantage. I bet there is also a reason why you walk left to check-in at the front desk.

Perhaps Beyonce knows more than she lets on...
Perhaps Beyonce knows more than she lets on…

The clinic is an interdisciplinary dream. The staff includes 5 physical therapists, an optometrist, a dentist, and a podiatrist. This setup allows for great communication among disciplines in order to provide the best individualized care for the patient at hand.

It was no big deal to call over the dentist to walk in and check out a patient during a session.

The physical therapists are where most people’s care starts. What is nice is they have several resources present to determine when to triage a patient to another provider. The clinicians had PRI glasses, orthotics, Asics shoes, mouth guards, and arch supports readily at their disposal.

Not everyone gets sent to another provider day 1 of course. Patients spend a few sessions working with one clinician, and if progress stalls then other options are undertaken.

The Session

A typical session at the clinic lasts 1 hour, and is all one-on-one care. Initial evaluations are very personalized to the patient, and much time is spent getting to know that individual. Not just from a physical therapy standpoint, but on a personal level. It was quite refreshing.

Almost as refreshing.
Almost as refreshing.

Objective examination consisted predominately of PRI testing, followed by large amount of education on pattern and position.

 Most of the clinicians utilized various analogies to describe how PRI is performed. I heard various things ranging from car alignment, to wings on a plane, but what was emphasized with all these alignment-based analogies was that this position is normal. It is our position of comfort.

They also use the tests, and how quickly tests change, as educational pieces. The clinicians also liked showing natural asymmetries, such as the preference in which one crosses his or her arms, or the way one stands.

I personally would’ve like to see more pain neuroscience-based education, as you could see some patients start to get a little concerned regarding what was being told. The patient’s still got better of course, but anything to reduce threat perception is critical.

I can’t count how many times I’ve seen hip internal rotation measurements improve after a successful therapeutic neuroscience education session. Perhaps a PRI pain science affiliate course is in due order? 🙂

 

It's a possibility.
It’s a possibility.

After education, the exercise program was implemented. Few exercises are given, but they are worked on for a large period of time. Form is to be impeccable by the end of the session. This work is needed since most patients are seen only once every one to two weeks. I love this frequency because the locus of control falls directly on the patient.

Helpful Tidbits

That’s pretty much the general clinic flow, and in my opinion it is the ideal treatment setup for patient success. The interdisciplinary care alone creates large variability in types of patients seen. Diagnoses I saw included pectus excavatum, “brain fog”, POTS, and chronic pain of all sorts. To me, that is the power of targeting the autonomic nervous system. You can affect any “diagnosis” that has an autonomic component; something PRI has a leg up on compared to most.

The remainder of this post is just going to include some various tips I picked up while there. The Hruska Clinic is definitely a neat place to see and worth the price of admission to observe (it cost $250/day to hang out).

 I Have a Vision

 You might be a vision patient if…

  • Have to reread pieces frequently.
  • You track with your finger (finger becomes a reference center to help your eyes track).
  • You have blurred vision.
If only Jeff Foxworthy grew up in Nebraska.
If only Jeff Foxworthy grew up in Nebraska.

I also got to observe a patient in PRI vision. It was a cool experience especially after going through it myself.

The patient had a 3-level cervical spine fusion with chronic neck and lower back pain. It was clear that the pain system was  centrally sensitized, but what about the visual system?

As the patient walked, you could see minimal trunk rotation, large amounts of valgus collapse and pronation. Heidi, the resident optometrist, altered the patient’s lenses by 0.25 diopters. With that small change alone, the patient began walking with pelvic and trunk rotation, as well as decreased knee and foot collapse. She also reported less pain. So as we can see, the pain system is not the only system that becomes sensitized in chronic pain. Multiple systems, dare I say the individual, becomes sensitized.

“That’s a sensitive system.” ~Ron Hruska

It is possible that pain could increase with glasses on if tone is brought down low enough. The stability created by tone is taken away and control of new neurological space is not present. This is a threat to the system, which could lead to a pain experience in order to protect the patient.

Other tips:

  • PRI Vision Lite – Put reading glasses on someone and see if they let go. I personally have done this for several patients and it has worked wonders. I Had a woman who had shoulder pain, and I tried just about everything I could think of to alleviate her symptoms. No change. She puts on a pair of +1.0 reading glasses = no shoulder pain.

 

At a PT clinic near you.
At a PT clinic near you.

All Bite, no Bark

I generally have a hard time explaining how the stomatognathic system can play a role with various complaints, but one piece stood out to me quite well:

“If you have a piece of hair in your mouth, you can immediately feel it.”

This instance shows just how sensitive teeth can be. The stomatognathic system is neurologically-rich area for sensory input, and the trigeminal nerve has links to multiple body areas.

Other neat things I picked up:

  • Test patients by having them line up their three fingers in their mouth to rule out bite as a driver of position. This position allows the discs to rest.
  • On pulling teeth: If you are missing teeth you are missing a reference. So don’t pull if needed or neutral. Try to create room first. If that is not possible, then teeth must be pulled.
Aka my wisdom teeth. Jerks.
Aka my wisdom teeth. Jerks.

Testing Tips and Tricks

  • Watch how a shirt wrinkles when someone walks to see if trunk rotation is occurring.
  • If someone is sitting in bilateral hip internal rotation, the psoas is likely kicking in as an external rotator and pulling the spine forward.
  • During the Hruska adduction lift test, areas need to be felt. If you can’t feel something, then you need to inhibit something. Should feel at least 5/10 activity rating.

Nonmanual Tips and Tricks

  • For Exhaling – Think about the sigh you make when your mom and dad tell you to clean your room.
  • If someone gets excessive cramping with an activity, you need to inhibit something.
  • When performing a step up and over, reach forward with the right leg.
  • If the patient is having a hard time feeling the left IC adductor, go after the right intercostal.
  • If TFL or glute med kick in during an activity and the IC adductor is not felt, perform pure adduction activities with the knee and hip extended.

 

Likely neutral through most of my childhood.
Due to frequent exhalation, I was likely neutral through most of my childhood.

Manual Tips and Tricks

  • [Comparing manual to nonmanual techniques] – Left arm reach is equivalent to a left pec mobilization; right arm reach is equivalent to a subclavius release.
  • A good manual technique – Use your hands to create OA extension by providing a patient with a cervical lordosis. This is how I feel traction ought to be truly done. As when you perform traction (anyone still do that?), cervical lordosis is reduced.

Clinic Quotes

  • “We don’t have proof, just a theory.”
  • “As your bite changes your vision is going to change.”
  • “Every time I touch my teeth I twist.”
  • “A balloon is theratube for your abs.”
  • “We don’t know.”
  • “If you’re not sleeping you’re not living.”
  • “All clenchers and grinders have no reference. Period. End of discussion.”
  • “I’m so sorry to make you do that.”
  • “The pattern doesn’t cause pain, but is an influence.”
Unless...ya know.
Unless…ya know.