Third Time’s a Charm A trip home and hearing Mike Cantrell preach the good PRI word? I was sold. 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! I have way too many gems in my notes to discuss, so here are a few big takeaways.
Read MoreAuthor: Zac Cupples
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. 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.
Read MoreManual 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%!!!!!!!!!!!! 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 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.
Read MoreCourse Notes: Spinal Manipulation Institute’s Dry Needling 1
You Mean Zac Didn’t go to a PRI Course? Yes. From time to time I occasionally take a gander at what else is out there in PT land. It was probably about time I check out this whole dry needling thing and see what the fuss is about. I took the Spinal Manipulation Institute’s version based on some recommendations from a few colleagues I trust. Ray Butts was MC’ing for the weekend. I know needling is quite the controversial topic, but I was amazed at the sheer quantity of evidence supporting this modality. Like, an insane amount. I am not sure what the “haterz” found their criticisms on, so please comment if you have some ammo (I am a noob to this after all). And Ray’s lecture on dry needling mechanisms? Oooohhh lawwwwd. Easily one of the best foundational science lectures I have ever heard. Period. The passion this group has not only for science but the physical therapy profession is inspiring. They made me excited to be a PT. Perhaps even inspired me to contemplate the PhD route. All that said, I am unsure as to where needling will fit into my practice. The assessment that would point you toward needling someone was sorely lacking. I’ve noticed this problem to be quite common in manual therapy courses. It’s pretty much you hurt here/have this diagnosis, then use this protocol.
Read MoreCourse Notes: PRI Cervical Revolution REMIX
Note: I made some errors on the first rendition of this blog that were corrected after speaking with Eric Oetter. Courtesy to him, Lori Thomsen, and Ron Hruska for cleaning up some concepts. Four Months Later When the Lori Thomsen says to come to Cervical Revolution, you kinda have to listen. I was slightly hesitant to attend since I had taken this course back in January. I mean, it was only the 3rd course rendition. How much could have changed? Holy schnikes! It is simply amazing what four months of polishing can do. It was as though I attended a completely different course. Did I get it all figured out? No. But the clarity gained this weekend left me feeling a lot better about this very complex material. This is a course that will only continue to get better with time; if you have a chance to attend please do. Let’s now have a moment of clarity. Biomechanics 101 The craniocervical region is the most mobile section of the vertebral column. This mobility allows regional sensorimotor receptors to provide the brain accurate information on occipital position and movement. The neck moves with particular biomechanics. Fryette’s laws suggest that the cervical spine produces ipsilateral spinal coupling in rotation and sidebending. The OA joint, on the other hand, couples contralaterally. C2 is the regulator of cervical spine motion; much like the first rib regulates rib cage movement. C2 is also important for the mandible, as it balances the cervical spine during mandibular
Read MoreCourse Notes: BSMPG 2015
#Bestconferenceevaahhhhh I shipped off to Boston to attend my first ever BSMPG summer symposium. And it was easily one of the best conferences I’ve ever been to. There was an excellent speaker lineup and so much of my family. Art Horne really put on a fantastic show. If you haven’t been to BSMPG before, put it on your to-course list. It is one of the few courses that has a perfect combination of learning and socializing. I hope to not miss another. Instead of my usual this person talked about that, let’s look at some of the big pearls from the weekend. Why Sapolsky Doesn’t Get Ulcers In one quote Robert Sapolsky summed up my current foundational premise to rehabilitation and training: “The stress response returns the body to homeostasis after actual or potential threats.” ~ Robert Sapolsky Regardless of what your malady is, it can probably be linked back to the stress response gone awry. The specifics become irrelevant because the stress response occurs nonspecifically. This response works best against acute crises. Guess how we screw it up? Chronic stressors. Human stressors are quite different from other species’ as we have the capability of inducing this stress response psychosocially. Gazelles on the Serengeti don’t have to worry about student loans. We can see how chronic stress becomes an issue when you look at what occurs in the stress response: Glucose travels to the bloodstream to mobilize energy. Increased cardiovascular tone, heart rate, and blood pressure. Decrease long-term building projects such as
Read MoreCourse Notes: PRI Interdisciplinary Integration 2015
A Stellar Symposium Back in April I had the pleasure of finally attending PRI’s annual symposium, and what an excellent learning experience. The theme this year was working with high-powered, extension-driven individuals. The amount of interdisciplinary overlap in each presentation made for a seamless symposium. Common themes included the brain, stress response, HRV, resilience, and drive. These are things altered in individuals who are highly successful, but may come at a cost to body systems. If you work with business owners, CEOs, high-level athletes and coaches, high level positions, straight-A students, special forces, and supermoms, this symposium was for you. And let’s face it; we are both in this category! There were so many pearls in each presentation that I wish I could write, but let’s view the course a-ha’s. The Wise Words of Ron Ron Hruska gave four excellent talks at this symposium regarding high performers and occlusion. Let’s dive into the master’s mind. People, PRI does not think extension is bad. Extension is a gift that drives us to excel. Individuals who have high self-efficacy must often “over-extend” themselves. This drive often requires system extension. Extension is a consequence, and probably a necessary adaptation, of success. If this drive must be reduced to increase function and/or alter symptoms in these individuals, we have to turn down the volume knob. How can we power down these individuals? Limit alternate choices – These folks take a wide view of a task Set boundaries – These folks attribute failure to external factors Making initial
Read MoreSmooth Talker: Nonthreatening PRI Patient Education
I recently had the pleasure and honor of speaking at the annual PRC conference at this past weekend’s Interdisciplinary Integration. I happened to have my younger older brother Connor Ryan record the event. We unfortunately had some technical difficulties, so a few bits are missing. But you’ll get the gist from the videos below. Enjoy! Smooth Talker handout
Read MoreThe Road to an Alternating and Reciprocal Warrior: You down with ENT?
This spans an entire treatment over a year’s time. Here’s part 1 Part 2 Part 3 Part 4 “Yeah you know me.” ~ Naughty By Nature You know how sometimes when you are treating someone that individual eventually reveals fairly important information that he or she forgot about. Yeah that was totally me. I’ve always had a stuffy nose as far back as I can remember; especially in the winter. The only time breathing felt incredibly easy was when I was eating paleo in college. I have progressively been losing my sense of smell as well. Must be old age right? When I spoke with Lori Thomsen about my recent experience, she mentioned at Pelvis that attaining neutrality in certain areas but not others could lead to a “pressure cooker” phenomenon. For example, if I have someone with a neutral neck and thorax, lower extremity symptoms may possibly be more common. In my case, I had a neutral pelvis at the time my wisdom teeth were pulled. Pull out wisdom teeth and my nasal airway goes crazy. Guess where the pressure went? It was time to see an ENT. ENT Begins After viewing my CT scan and airway, my ENT concluded I have patho-scoliosis. More specifically, airway scoliosis. He found a deviated septum and some enlarged turbinates. These two factors could have a large impact on my breathing capabilities. To me this made a lot of sense. If you read this article, a nostril will drive air to the ipsilateral lung.
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Course Notes: Pelvis Restoration Reflections
Pelvises Were Restored It was another great PRI weekend and I was fortunate enough to host the hilarious Lori Thomsen to teach her baby, Pelvis Restoration. Lori is a very good friend of mine, and we happened to have two of our mentees at the course as well. Needless to say it was a fun family get-together. Lori was absolutely on fire this weekend clearing up concepts for me and she aptly applied the PRI principles on multiple levels. She has a very systematic approach to the course, and is a great person to learn from, especially if you are a PRI noob. Here were some of the big concepts I shall reflect on. If you want the entire course lowdown, read the first time I took the course here. Extension = Closing Multiple Systems This right here is for you nerve heads. It turns out the pelvis is an incredibly neurologically rich area. What happens if a drive my pelvis into a position of extension for a prolonged period of time? I’ve written a lot about how Shacklock teaches closing and opening dysfunctions with the nervous system. An extended position here over time would increase tension brought along the pelvic nerves. Increased tension = decreased bloodflow = sensitivity. We can’t just limit it to nerves however, the same would occur in the vasculature and lymphatic system. We get stagnation of many vessels. Perhaps we need to think of extension as system closure; a system closing problem. Flexion will be
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Recognizing and Changing Nonverbal Communication Disorders: An Interaction Approach
I was at my local coffee shop the other day chatting with my barista as she prepared my drink. Once it was all said and done and I paid, she wished that I had a glorious day. Glorious is not a word you hear often and definitely caught me ear. You might even say it was salient! I have this thing when someone uses an uncommon descriptor. When this occurs, I typically try to use an even more ridiculous descriptor. I especially like to apply this method to wish someone a better day than I. For example: Joe Blow: “You have a good day.” Me: “You have an even better day.” Glorious is a bit more difficult to top, but in the blink of an eye I was able to respond: “You have a splendiferous day.” Stupid? Yes. Did I get a laugh and a smile? Absolutely. Me doing this silly little thing with people is irrelevant. What is relevant is the speed that I was able to apply this quip. I spouted this word quickly because it fit a common pattern. Pattern recognition is huge in athleticism, medicine, and a multitude of other life facets. But how often do we think of pattern recognition when we interact with individuals? Being able to differentiate what both verbal and nonverbal communication one uses is critical in ensuring a favorable interaction with someone. And if your patient or client doesn’t like you? Fugetaboutit. Let’s look at a very common pattern that if you allow
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It’s the Salient Detection System, Stupid
Can you tell the difference among pain, depression, and pleasure? From a neurotransmitter perspective, the answer is no (see here and here). How is it that three very different states can be so neurologically similar? I feel the commonality that the nervous system purports reflects a system that responds to stimuli that are deviations from the norm. We call these instances by this word: Salient. Doesn’t that make your loins quiver? Let’s discuss how it works. Here’s your recommended reading. 1. The pain matrix reloaded: a salience detection system for the body (Thanks Sigurd) 2. Stress signalling pathways that impair prefrontal cortex structure and function (Thanks Son) 3. From the neuromatrix to the pain matrix (and back) [Note: Most of this article is an amalgamation of the three articles that I cited above and my own thoughts. Rather then cite every sentence AMA-style, I’ll give the credit to these guys above. Read ‘em and figure out how I put this together. For those who are sticklers for proper reference formatting, the type I am using is KMA-style citation.*] The Pain Neuromatrix Myth Hate to break it to you, but pain ain’t so special. Here’s why. If you follow modern pain science, you may often hear the term pain neurosignature or neurotag. This phrase is meant to describe a cluster of brain areas that are active during a pain experience. Information that can contribute to a pain experience travels to several areas. Some of the big players are the primary and secondary somatosensory cortices (all the
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