Intro to Hand Therapy Course Review

The hand has always been a weak area of mine, anatomy, treatment, the whole 9 yards. Thus, I was inspired to take an Intro to Hand Therapy Class taught by Patricia Roholt, a certified hand therapist (CHT) with 30+ years of experience.

 The intent of this class was to provide a broad overview of all things hand therapy.  We dove into hand anatomy, evaluation, treatment, splinting, and specific conditions.

My favorites parts were the anatomy, evaluation, and splinting sections. All of these areas were weak points of mine, and I definitely achieved quite a bit of clarity with these concepts. P-Ro is an absolute monster when it comes to splint making, and I loved all the tricks up her sleeve she had to make effective splints. It’s an area I’d like to dive into a bit more.

if the above areas are what you consider to be a hole in your game, I’d consider checking out her online offerings to see if her courses would be right for you.

Check out the full review in the video below. Once you got my final verdict, check out some of the meaningful highlights in the notes below.

Hand Anatomy

Let’s look at some of the fascinating anatomy that accompanies the hand.

The Carpal Bones

Laying your anatomy foundation starts with carpal bone appreciation, and the potential accompanying clinical problems.

‘ppreciate these bones, fam

As you can see, there are two rows of carpals. In the proximal row, the scaphoid and lunate articulate with the radius, and the lunate and triquetrum articulate with the ulna. The pisiform is in this row as well, but doesn’t articulate with any other bones. Its function is to allow for passing of the ulnar nerve and artery, and provide a distal attachment for the flexor carpi ulnaris (FCU).

The big red clinical red flag that can occur in this row is a scaphoid fracture. Because of poor blood supply to this bone, people often needed to be casted for 2-4 months to allow for healing.

Fractures in this region are often not immediately visible on imaging. Thus, a subsequent x-ray ought to be performed 2-3 weeks after the initial injury.

The second row of carpal bones consists of the trapezium, trapezoid, capitate, and hamate.

The trapezium is a bone of interest. In individuals undergoing surgery for thumb carpometacarpal joint (CMCJ) arthritis, part or all of this bone is often removed to increase space. Space is further increased by harvesting the palmaris longus tendon and shaping it into a pseudo-trapezium.

The Hand’s Retinacular System

The retinacular system ensures that tendons stay adhered to the hand while gliding, allowing for optimal hand function.

We can break up the retinacular system into three areas:

  • Extensor retinaculum – made up of six compartments (with first compartment potentially contributing to DeQuervains tenosynovitis)
  • Flexor retinaculum – Contain several synovial sheaths. Fingers II-IV all have their own sheath, whereas fingers I & V share a sheath.
  • Finger retinaculum

The most complex of these systems is the finger retinaculum. There are several pulleys that compose this system to adhere the flexor tendons to the finger: five annular pulleys (A1-A5) and three cruciate bands.

These pulleys are arranged in the following sequence:

Well I’m no Picasso, but do you like it?

For reference, here are the location of the Annular pulleys:

  • A1 – Metacarpophalangeal Joint (MCPJ)
  • A2 – Half the length along the proximal phalanx
  • A3 –Proximal interphalangeal joint (PIPJ)
  • A4 – Middle phalanx
  • A5 – Distal interphalangeal joint (DIPJ)

Trigger finger is a condition implicated within this system. Inflammation and swelling can adhere flexor tendons to the A1 pulley, restricting finger extension. Surgically, the A1 pulley is cut to alleviate this condition.

The Zones of the Hand

There are five zones of the hand to describe portions of the volar surface. It is important to know these zones from a surgical standpoint.

Pink = zone 1; black = zone 2; purple = zone 3; green = zone 4; blue = zone 5

 

  • Zone 1 – Proximal to Flexor digitorum profundus (FDP) insertion
  • Zone 2 – From Zone 1 to A1 (considered no man’s land due to poorest recovery times, as hand intrinsics reside here)
  • Zone 3 – From A1 pulley to volar carpal ligament
  • Zone 4 – Carpal tunnel
  • Zone 5 – Proximal to carpal tunnel up through forearm

Keeping flexor tendons healthy post-surgery involves differentially gliding their tendons. These movements help prevent flexor tendons adhering to the pulleys.

To understanding how to effectively perform these maneuvers, we need to understand flexor tendon muscles.

The big two that we are differentiating are flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP).

FDS primarily flexes the PIPJ…

Don’t stress about the FDS

 

…while FDP flexes the DIPJ.

You down with FDP? Yeah, you know me.

 

Thus, maneuvers must be performed to ensure individual gliding:

It is also important to note that FDP has two separate muscle bellies: one that goes to finger II, and the other that is shared by III-V. Thus, injuries along these particular areas require protection of all fingers, and may require joint blocking exercises to ensure tendon health.

The Extensor Mechanism

Whew, this part is a beast and very complicated structure. Let’s see if we can sift our way through it.

So gangsta that I grew up on that extensor hood, fam!

Here we see all the pieces that make up the extensor mechanism, which combines hand extrinsic and intrinsic muscles.

Let’s start with extensor digitorum communis (EDC), which acts to extend the MCPJ. This guy runs centrally along the finger, and splits off into sagittal bands that surround and stabilize the MPJ. In the picture, these would be a part of the “hood.”

Makes me think of that Wu-tang song every time

The EDC attaches to the middle phalanx, assisting with PIPJ extension. The fibers then split off into lateral bands, which are the criss crossed above past the middle phalanx. These bands are a merging with the hands intrinsic to perform DIPJ extension. The other muscles that would make up the lateral band insertion include the dorsal and palmar interossei, and the lumbricals—all helping to create DIPJ extension.

The Thumb

The big thumb intrinsic muscles are the called the thenar muscles, which help the thumb perform the important opposition movement. These include…

  • Abductor pollicis brevis
  • Flexor pollicis brevis
  • Opponens pollicis
Scalpel not included

These muscles attach proximally at the volar carpal ligament. This attachment is important to consider with someone who has a carpal tunnel release, as this surgery disrupts the thenar muscle attachment, potentially compromising thumb function.

Nerve Supply to the Hand

The big three nerves relevant to the hand are the median, ulnar, and radial nerve.

Yellow = Median; Green = Ulnar; Pink = Radial

The median nerve is the big dog when it comes to thenar muscles and first two lumbricals. Injury to this nerve will impact thumb opposition and sensation.

The ulnar nerve innervates many of the muscles of the hand, including lumbricals 3 and 4, all the interossei, and the hypothenar muscles. Thus, an injury to this nerve can have severe repercussions to hand function. Limitations could include inability to perform a lateral pinch (requires adductor pollicis activity), can’t abduct finger V (need abductor digiti minimi), and will have difficulty utilizing extensor mechanism.

The radial nerve is less of a big dog, predominantly responsible for sensation. There will be alterations in wrist and finger extension, but since hand intrinsics are innervated by the median and ulnar nerve, some finger extension is preserved.

Common Hand Pathologies

Ever seen a swan neck or boutonniere deformity before?

Finger 4 is a swan neck, finger 5 is a boutonniere

With a swan neck deformity, the proximal interphalangeal joint (PIPJ) upwardly displaces secondary to a disrupted  transverse retinacular ligament. These ligaments prevent dorsal displacement of the lateral bands.

With the boutonniere deformity, a PIP extensor tendon defect causes the proximal phalanx to migrate upwardly as the DIPJ extends.

The de facto treatment for the boutonniere is splinting the PIPJ in extension and the DIPJ in flexion.

Evaluation of the Hand

 

Most of this section was your typical evaluation fare: history, range of motion, posture, palpation, etc. But there were a few key pearls I gleaned.

Measuring Thumb Opposition

Measuring opposition according to this grading system is something I am employing much more. We measure opposition via a 10-point grading criteria:

  • Stage 0 – Thumb tip to lateral aspect of proximal phalanx of index finger
  • Stage 1 – Thumb tip to lateral aspect of middle phalanx of index
  • Stage 2 – Thump tip to lateral aspect of distal phalanx of index
  • Stage 3 – Thumb tip to index tip (considered early true opposition)
  • Stage 4 – Thumb tip to middle tip
  • Stage 5 – Thumb tip to ring tip
  • Stage 6 – Thumb tip to small tip
  • Stage 7 – Thumb tip crosses small finger DIPJ
  • Stage 8 – Thumb tip crosses small finger PIPJ
  • Stage 9 – Thumb tip crosser small finger proximal finger crease
  • Stage 10 – Thumb tip crosses distal palmar crease.

With stages 6-10, you want to make sure that the thumb slides down the small finger to ensure accurate opposition, as patients can compensate with thumb adduction, providing a false measure.

Sensation Return After an Injury

There are many ways to assess post-injury nerve function. One test used is tinel’s, in which you tap along the nerve to determine nerve regeneration. If you tap a portion of the nerve, it will produce an electric shock sensation to the point where the nerve has regenerated. This test can also signify potential nerve entrapment.

Based on how the nerve heals, constant and moving touch are some of the first sensations to return. Until these sensations are felt, true sensory re-education cannot be performed.

Wound Classificiations

 A weak spot of mine has always been wound care. Patricia helped stratify decision making for wounds in this class by classifying wound healing types. There are three.

First Intention

This type of wound is a sutured wound, in which range of motion across joints that may compromise the wound ought to be limited for 2 weeks after initial suturing.

Second Intention

This type of wound is an open wound, in which the treatment varies. The intent is to maintain a wound that is not too dry or wet.

Third Intention

This wound is intentionally left open at first to clean and debride, then is sutured and grafted once healed. Treat as a second intention wound until suturing/grafting occurs, then first intention once the wound is closed.

Scar Healing Times

 Scars have a specific healing times as well in the hands, which drive decision making in terms of progressing range of motion.

Coloring can be informative of how well the scar is healing. Typically, the redder the scar, the more immature the tissue is. Whereas white scars are a bit more mature.

Compared to normal skin, scar strength improves according to the following timeline:

  • 2 weeks:3-5%
  • 3 weeks = 15% (tolerates AROM)
  • 4 weeks = 30-50% (safe for most activities)
  • 2 months (70%)
  • 3-6 months (80%).

Splinting the Hand

 The splinting section was one of my favorite aspects of the course and really where Patricia shined.

The overarching goal of splinting is to give the hand what it cannot achieve.

Splints can be classified into three different types, either prefabricated or custom:

  1. Static – These splints lack moving parts, used for rest, protection, positioning, or function in some cases (e.g. nerve injury).
  2. Serial static/static progressive – These splints are used to increase mobility in joints and soft tissues via low load long duration stretching. The former requires therapist-remolding, whereas the latter is changed by modifying components (screw/Velcro)
  3. Dynamic – Splints that contain moving parts to compensate for motor loss, correct for contracture, protect tendons (by pulling in direction they cannot actively contract), or exercise muscles.

There were several different types of splints she suggested, but the real treat was watching her make splints. She had developed some pretty neat tricks to save on cost and maximize function. I don’t necessarily have any specifics, as the splints she makes were quite customized to the individual’s needs.

The Ideal Position to Splint the Hand

To illustrate important components of hand anatomy, it helps to look at how the hand is often splinted after an injury.

I’d rather some more IPJ extension, but like me, this splint is close to ideal, though not perfect #yesimsingleladies

The common position to splint the fingers in is with the MCPJ in flexion, and the PIPJ and DIPJ  in extension.

This position maintains tautness of all the collateral ligaments of each joint: the MPJ collaterals are taut in flexion, and the PIPJ and DIPJ in extension. This position also protects the volar plate, which is a ligamentous structure that limits PIPJ hyperextension. These structures must be preserved at all costs to avoid contracture in these areas.

Sum Up

There is a broad overview of Patricia’s Intro to Hand Therapy course. Though not perfect, it sparked many treatment ideas for me and helped me better appreciate the complexity of the hand.

To summarize:

  • Understanding hand anatomy is important in developing treatment paradigms
  • Flexor tendons must be differentially glided to ensure health post-surgery
  • Splinting acts to give the hand functions it cannot achieve on its own

What tricks do you have up your sleeve for assessing and treating hand complaints? Comment below and let us know!

Photo Credits

Anatomist90

Becguglielmino

Henry Gray

Wikipedia

Anatomist90

Anatomist90

Harrygouvas

Henry Gray

Henry Gray

Grant, John Charles Boileau

Grant, John Charles Boileau

Resilient Movement Foundations Course Review

I recently had the pleasure of attending a class put on by my fellas at Resilient Performance Physical Therapy.

A jolly old time with old friends and new

I went to this course for a few reasons. First off, I of course support the home team. I can’t even front, Douglas Kechijian, Trevor Rappa, Greg Spatz, and I go way back, and are very much related through IFAST family and directly (Doug is my younger older brother, Trevor is my son, and Greg is my stepson #dysfunctionalfamily).

That said, there is were a couple big things I wanted to take away from this course, which I did in spades:

  • Mastering basic movement
  • Program design

In these two areas, the Resilient fellas delivered in spades. Knowing what good technique is in the basic movement patterns, how to coach, and how to regress, are all underappreciated topics that these guys teach quite well.

So should you take this course? An emphatic hell yes. I give a more indepth review as to why in the video below, so go ahead and check that out.

Once you got the verdict, check out my favorite takeaways in the course notes, and then for the love of God sign up for a course of theirs!

Click here to check out the Resilient Seminar Page

Continue reading “Resilient Movement Foundations Course Review”

The Derek Hansen Speed Seminar

It turns out the Hamptons isn’t just a place to live large.

It’s also a place where great learning can take place.

That is exactly what recently happened when me and my boizzz arranged a 1-day seminar with sprint coach extraordinaire, Derek Hansen.

and it was a total bro-down

For those who don’t know, Derek is one of the best sprint coaches in Canada, and had spent 10 years learning from THE Charlie Francis.

He is a wealth of knowledge in many areas, but the course focus was on all things sprinting, speed, acceleration, and periodization.

The setup we arranged was very unique. We watched Derek coach three different athletes on sprint mechanics, and watching the man work was quite remarkable. His ability to find the right cue, verbiage, and drill to attain improved sprint mechanics was remarkable. He is definitely an artist at his craft.

Point being, if you get a chance to hear the man speak, do so. You won’t regret it.

Without further ado, here are the notes.

[Note – I am not the best sprinter in the world, so bear with me on the videos]

Continue reading “The Derek Hansen Speed Seminar”

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 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. Continue reading “Course Notes: PRI Postural Visual Integration: The 2nd Viewing”

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
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. Continue reading “Course Notes: The Val Nasedkin Seminar”

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?
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. Continue reading “Course Notes: Explaining Pain Lorimer Moseley-Style”

Course 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.

He was a straight-up needling gangsta
He was a straight-up needling gangsta

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.

Then I looked at my student loan bill again.
Then I looked at my student loan bill again…

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. Continue reading “Course Notes: Spinal Manipulation Institute’s Dry Needling 1”

Course 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.

Especially when tempted with soufflé. Ooooooohhh Lawwwwd
Especially when tempted with soufflé. Ooooooohhh Lawwwwd

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?

There's no going back Ron
There’s no going back Ron

 

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.

Itsyabloig
Itsyabloig

 

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=1st rib = Nate Dogg (RIP)
C2 = 1st rib = Nate Dogg (RIP)

C2 is also important for the mandible, as it balances the cervical spine during mandibular opening. The reason this occurs is because the mandible and C2 are at the same fulcrum level.

images

 

Pathomechanics 201

Often triplanar motion will decrease amidst progressive respiratory demand or threat. These changes help promote neck stability while simultaneously increasing demand on the mandibular elevators, extraocular muscles, and vestibular system

If these changes occurs long enough, sensory issues may become prominent.

Stability can occur through increased sagittal plane activity in the upper cervical spine and cranium either one of two ways:

  • O on A via posterior cranial rotation
  • A on O via forward head posture

Both strategies attempt to flex the cranium, but both are undesirable if occurring underneath a lost cervical lordosis.

OA hyperflexion is often seen in those who sit in front of monitors for long periods of time. The visual system helps promote stability.

Aka actually sit in your freakin' chair!
Aka actually sit in your flippin’ chair!

OA Hyperextension is an attempt to create an airway. Cranial protrusion may be utilized as a way to open up the airway under stable conditions. This position passively raises the hyoid bone, which often depresses when one uses a mouth-breathing strategy. These individuals rely heavily on the dentition for craniocervical awareness.

Aka get a larger monitor
Aka get a larger monitor, and possibly a haircut.

Of course, these are not the only ways undesirable neck stability can occur.

You might have a stable neck if:

  • You have a narrow palate.
  • You have a cross bite.
  • You have a narrow airway.
Just think if Jeff Foxworthy were a dentist.
Jeff Foxworthy coming to a dental chair near you.

 

Patterned Mechanics 3037

 The TMCC is the foundational polyarticular muscle chain at the neck, with the right side generally more active than the left.

The normal RTMCC pattern presents with the following at the neck:

  • C2-C7 orientation in the transverse and frontal plane to the right, with compensatory rotation and sidebending to the left.
  • The OA joint is sidebent to the right and rotated left as a passive orientation.
Yep, that's you.
Yep, that’s you.

The RTMCC may be present in isolation or with various cranial strains.

A cranial strain may occur if the left SCM sidebends the OA left within the RTMCC pattern. This compensatory movement occurs to attempt to reduce OA rotation and upper cervical strain.

If you weren’t sleeping during the biomechanics section, you will notice that this goes against Fryette’s laws. In order for this compensatory strategy to occur, the right alar ligament and posterior capitis muscle must become lax. This movement does help reduce torsion and compression on the upper cervical segments, but may create a cranial lesion in the process.

This compensatory movement is a precursor to a left sidebending cranial lesion, and this lesion along with others are quite prominent.

According to a 2008 study by Timoshkin and Sandhouse, 72% of individuals have a cranium that is in a sidebend or torsion pattern; with left sidebend and right torsion being the most common.

Of those two cranial strains, the left sidebend will be the most common. Let’s dive into that pattern more.

Using whichever diving face you prefer.
Using whichever diving face you prefer.

 

Left sidebend (LSB)

The LSB lesion is named for the sphenoid’s greater wing position. In this case, the greater wing is high on the right and low on the left. The occiput matches this orientation.

Where these bones will differ occurs about a vertical axis; as the sphenoid externally rotates while the occiput internally rotates.

The mechanical change at the atlas drives this position. The sphenoid just goes along for the ride.

A prime example of this cranial strain would be the lovely Garey Busey.

Though his personality is a bit more right torsion
Though his personality is a bit more right torsion

Right Torsion (RT)

RT’s also have a low left greater wing of the sphenoid, but the big difference is at the sphenobasilar joint.

Since the RT is a progression from the LSB, the occiput will attempt to sidebend right to level occipital position.  Since the sphenoid stays in position, torsion through the sphenobasilar joint occurs.

This twist is driven by the sphenoid as means to create pseudo-facial symmetry via extension.

Lorimer Moseley is actually a perfect example of this type of cranial position, as many facial features are flipped from a LSB face.

For the sake of science, I hope he is not offended.
For the sake of science, I hope he is not offended.

 

This is a Test

The only way to truly determine which cranial strain one has is through imaging, but PRI testing can guide us down a treatment path.

Admittedly, the cervical tests are not the most reliable of the PRI bunch. To attempt to offset this limitation, we shall imply a test battery to determine position.

There are four essential tests in the TMCC algorithm:

  • Cervical extension: Checks cervical lordosis presence; goal is 30-35 degrees.

If limitations are present it is likely that SCM hyperactivity is reducing the normal lordotic curve.

I think of this test as the extension drop test of the cranium. It tells you if you are working with someone who is sagittally lax or not.

  • Cervical axial rotation: Checking C7-T1 rotation, which reflects C2 position. Looking for symmetry at about 30-35 degrees of movement. This test determines the TMCC pattern.

Limitations will be present due to the cervical spine’s compensatory rotation and sidebend to the left. Placing the patient supine on a table rotates the spine further to the left, which places a RTMCC patterned neck in an end-range position. Hence, normally left cervical axial rotation is limited. We would see bilateral limitations in a BTMCC.

When performing this test you want to make sure that you do not give the patient a lordosis, for this can create false negatives.

  • Midcervical sidebending: I think of this test as the great comparer between the cervical spine and the cranium. Looking for symmetry at about 30-35 degrees. This test gives you a frame of reference for our next test.

In the RTMCC pattern, this test is limited to the right secondary to an arthrokinematic block. If the cervical spine is rotated left on the table, the neck cannot sidebend to the right. That’s Fryette’s laws brah!

  • OA sidebending: This test looks at cranial position. Looking for 8-10 degrees bilaterally.

More than 10 degrees of sidebending would indicate alar ligamentous laxity.

A  RTMCC individual would have limited right OA sidebending due to a bony block. In someone with a LSB however, you would have limited L OA sidebending because the left SCM pulls the OA over to the left. A RT could present with just about anything, as pathology is quite prominent in these folks. 

Cranial Destraining

 RTMCC repositioning and retraining goes about the following progression:

Cervical spine → OA joint → Mandible

The neck is the top priority because its mobility maximizes cranial sensory activity.

Moreover, most cranial activities are integrated multi-joint movements. Spending time doing “basic” PRI sets the foundation for one to combine complex movements.

But sometimes that's what you gotta do
But sometimes that’s what you gotta do

Mandibular movement is often normalized by the time the neck is cleared. The reason TMJ mobility may be limited because of craniomandibular discord.

In the RTMCC pattern, the right lateral pterygoid works with the right anterior capitis and right SCM to deviate the temporal bone and mandible to the left whilst the occiput (and sphenoid) are “stuck” in the left sidebend position. In a neutral system, we would expect the occiput and sphenoid to move to the right during this cranial movement. This tonal issue could limit mandibular movement.

Thus, a neutral cranium often restores normal TMJ mechanics. If problems still arise, then mandibular re-education may be necessary.

Sometimes you need a Dentist

 

Must be LVI-trained.
Though not all appreciate occlusion.

Of the two common cranial strains, RTs will most likely need integration.

With normal occlusion, one side of teeth should touch while the other discludes. This alternation creates lateral shifting in both the mandible and the cranium.

The canine teeth act as guides for where the jaw ought to be in space. When canines touch during shifting, molar contact follows as the teeth drop into position. This action is called group function.

Teeth touching is kinda important.
Teeth touching is kinda important.

If group function cannot occur, it is likely that a dentist may need to be involved.

Splint therapy is generally recommended in these cases. More specifically, mandibular splints are the go-to (which I spoke about here and here).

Maxillary splints are generally the devil. These splints tend to increase tongue activity and mandibular clenching to hold the splint in. The one major case that may warrant a maxillary splint is the presence of tori.

Wolff's law at its finest.
Wolff’s law at its finest.

Even if not using PRI splints, there are four essential pieces needed from a dentist:

  1. Don’t lock the mouth into a position.
  2. Move head back and jaw forward with canines.
  3. Feel one side occlude while the other side discludes.
  4. Have group function and anterior guidance between incisors.

Note – anterior guidance is when the incisors touch the molars disclude

 

#Explainocclusion

 You might be wondering how I educate people about this stuff in a nonthreatening fashion. I got this neat little tidbit from the Ronimal:

“Periodontal ligaments are so sensitive that a hair will throw off your gait.” ~ Ron Hruska

Think about that statement the next time you get something stuck in your teeth. Drives you crazy right? If there is something undesirable going on with your teeth, you will know about it in some way. Some output will occur.

Yes, it's called a chiari malformation
Yes, it’s called a chiari malformation

Moreover, think about what occurs at the dentition when stressed. Do you clench? Reducing this muscle over activity by splint therapy introduces a salient stimulus that could reduce the stress response, if the craniocervical region is involved.

Hint: It usually is.

Infamous Ron Quotes

  • “Every single bunion and ACL patient is a TMD patient.”
  • “I love dentistry, but I don’t like dentistry, but I like dentistry.”
  • “You cannot treat a neck if a neck can’t treat itself.”
  • “We are a product of how we move our cranium.”
  • “A bra strap will really mess a tongue up.”
  • “The worst thing you can do to a patient is splint their neck.”
  • “We still have a lot of goniometric minds.”
  • “What good is the polyvagal theory if you don’t understand the neck.”
  • “Don Neumann is the best book for 1% of the population.”
  • “Treatment starts when you appreciate frontal plane.”
  • “How can you treat a TMJ if you can’t control the T?”
  • “The vehicle you drive is not the problem, it’s the path your on.”
  • “A twisted levator is an untwisted neck.”
  • “Hallelujah you have a pattern.”
  • “When you lose your left ab wall the head and neck will pick up the slack.”
  • “You can learn a lot about cognition and personality if you look at a neck.”
  • “You can’t feel CSF flow if you lack a cervical lordosis.”
  • “Make sense out of sense.”
  • “A neck that can’t move will produce a cant.”
  • “Crossbites, pulled bicuspids, and high arches scare me.”
  • “Sedentary lifestyle and screens demand we go straight.”
  • “The pattern is sugar that tastes pretty sweet.”

Course 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.

And we grow more everyday.
The League of IFAST grows stronger every day.

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.

what your symptoms are.
what your symptoms are.

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.

 

I have thought about it on more than one occasion
I have thought about this viable option on more then one occasion

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 digestion, growth, and reproduction.
  • Increase immune system activity
  • Sharpen cognition, alertness, and pleasure

If the stress response perpetuates, other systems fail and break down to continue to support the need to reduce potential threats. We see a shift in the homeostatic set-point toward elevated levels of the above.

Although we all must deal with stress in some way, why is it that some people tolerate chronic stress better than others? It’s all in how one copes. The following is needed to successfully deal with stress:

  • Need an outlet for stress.
  • Have predictable information.
  • Have a sense of control.
  • Have a healthy social circle.
  • Perceive that life is improving.

 

Stress Antifragility

Per the book of Sapolsky:

 

Optimal stress = moderate severity + shorts duration/amount + safe/benevolent environment.

 

Aka good training. But how do we build up individuals to continually better tolerate further challenging stressors?

Here is where my man Eric Oetter dominated the conference.

My 2 favorites from the weekend.
My 2 favorites from the weekend.

When chronically stressed, the aforementioned stress response takes high priority in all our systems, including nervous. Immune molecules smudge our various homunculi, dopamine floods the system to reward outputs, and myelin solidifies neurological pathways to perpetuate it.

Breaking a chronic stress cycle involves habit alteration.

To be able to effectively create newly favorable habits, movements, or pathways, attention is key. This piece is something we lose in a stressed state; as prefrontal cortex activity decreases. This is why salience is so important.

To return to a favorable homeostatic environment, we enlist Eric’s three P’s:

 

#Prime

 

Both prime and Prhyme are essential
Both prime and Prhyme are essential

Prime brain activity via the aerobic system. It boosts brain power, especially if done before an activity.

 

How: Work between 120-150 bpm for 15-30 minutes prior to motor skill learning. Do something you enjoy so you do not become overly stressed by the activity itself.

 

#Prune

And helping you learn since 10000 BC
And helping you learn since 10000 BC

Sleep is a big deal. According to one of the speakers, Vincent Walsh, we sleep 37% of our lives. Yet we only work 19% of them. We sleep so damn much that it should probably be taken seriously.

Sleep helps us remember by helping us forget things. The sleep cycle replays our day; keeping the important pieces and discarding the unnecessary.

This discarding is the pruning that Eric referred to, and it occurs by glial cells. Glia is what smooths out new neural connections.

How do we get good sleep?

  1. Respect the chronotype – keep your normal sleep-wake cycles.
  2. Take naps – 26 minute naps are bomb.
  3. Banish blue light – cut out 1-2 hours before bed, as blue light from electronics tells the suprachiastmatic nucleus in the brain that it is light out.
  4. Become a sleep environmentalist – No caffeine after 12, no meals 3 hours before bed, sleep in a cool room, etc.

 

#Prefrontal

If you can’t access to the prefrontal cortex, you will never hit the cognitive stage of motor learning.

Chronic stressors inhibit access to the PFC. The PFC is the doorway to variability, which is something unwanted during a stress response. Automaticity is king.

Getting the PFC allows all systems to be freely expressed. How do we do it?

  • Mindful meditation.
  • Monitoring (omegawave, bioforce HRV, etc).
  • Remove the “neurolock” via redirection and respiration (hint hint– PRI)
  • Energy systems development.

 

Respect the Thorax

 This section will channel my homie’s James Anderson and Allen Gruver. Can’t go a place without getting a PRI fix.

It's quite uncanny actually
It’s quite uncanny actually

What keeps the spine and sternum oriented right despite the thorax counter-rotating to the left? The answer would be airflow. A hyperinflated left chest wall pushes these areas to the right.

Thoracic movement is determined by this position as well as timing/coordination of gross movement patterns. We can observe how the thorax is driven through what the extremities are doing.

If you look at the baseball throw, we ought to see alternate positioning on each arm. For example, if the right forearm is in supination during a part of the throw, the left arm ought to be in pronation. This reciprocal arm function promote the thorax rotating in one direction. It’s a PNF thing.

Do you even PNF bro?
Do u even PNF bro?

If the arms go in the same direction, the thorax must extend or flex. Since sport is usually extension-driven, we can guess which direction one will go.

 

The Decision

Vince Walsh gave an excellent talk on the brain. He thinks we miss lots of talent because we look predominately at physical prowess.

Physicality is only one piece of the puzzle. Some individuals may develop excellent decision-making skills later on in their careers that may trounce athleticism.

Your ability to make right choices and avoid wrong ones is necessary for success, and is a trainable skill.

To know how to train it, it is important to understand the three types of decision-making:

  • Physical – What to do and not do (e.g. gun slinging)
  • Mental – e.g. poker playing
  • Temporal – e.g. playing chicken

Vince predominately used computer simulations to train these decisions, but it seems plausible that these tests could be applied to any type of training. Perhaps something like a reactive agility test could help improve physical decision making as an example. You just have to be creative.

 

For example
For example

A Cautionary Note on Data

Al Smith said some of the most profound words this weekend. He spoke to caution us on data.

Data does not always tell the individual story, as it can lead to less individualized training or rehab. It dehumanizes both our clients and us. This statement made me think quite a bit to those folks who champion evidenced-based everything.

Perhaps instead of measuring everything, one must first ask if there is a problem with what one is thinking of measuring.

Cynefin

Another cool thing Al Smith showed us was the cynefin framework; a sense making model in which acquired data precedes framework.

download

Depending on what a situation can be categorized in, one would expect to utilize different thought processes.

Simple – predictable relationship between cause and effect (use best practice)

 

Complicated – predictable relationship between cause and effect that’s not self-evident (use good practice)

 

Complex – A system without causality (use safe-fail experiments)

 

Chaotic – A completely unpredictable system (Use novel practice)

 

Where does training fit? Where does rehab fit? We may be using incorrect methods in particular situations.

You can learn more about the framework here, it’s definitely something I hope to explore more in the future.

Weekend Quotes

  • “Too much exercise is not normal hominid behavior.”
  • “This CT scan was not drawn by a commissioned artist.”
  • “If you think that’s a tight pec you better check pressure in the air.”
  • “10,000 hours can’t always undo 100 dumb ones.”
  • “Frank Netter shut down the left AIC.”
  • “Deny PNF and you are messing with the system.”
  • “We’re all barking down the same tree. We just like to complain.”
  • “No plan survives the first contact with the enemy.”
  • “Changing the answer is evolution; changing the question is revolution.”
  • “If you live in mediocrity you eventually think it’s good. You don’t know what good is.”
  • “It’s not normal to fart all day.”
No more complaining or whining. There is no bathroom.
No more complaining or whining. There is no bathroom.

Course 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.

Or a combination thereof
Or a combination thereof

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.

Enter at your own risk. Shizzzaahhhh
Enter at your own risk. Shizzzaahhhh

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?

  1. Limit alternate choices – These folks take a wide view of a task
  2. Set boundaries – These folks attribute failure to external factors
  3. Making initial tasks successful – So these folks don’t give up at early failures
  4. Objectively measure improvement – This helps motivate people to continue
  5. Establish rhythmic activity that reflects specific set goals – the higher the goals the more likely the positive change.
PRI, we have a bobsled team
PRI, we have a bobsled team

A Tale of Two Forward Heads

We discussed a lot of attaining neutrality at the OA joint. What does that entail?

A: Both occipital condyles centered in the atlas fossa with unrestricted lateral flexion.

What is needed to have that?

  1. 55-60 degrees of cervical extension.
  2. Equal bilateral first rib rotation position.
  3. Centric occlusion with the anterior teeth guiding protrusive movement and canines guiding lateral movement.
  4. Normal maxillary and mandibular teeth contact.
  5. Ability to nasal breathe.
  6. Alternating pelvic capability.
  7. Visual flexibility.
  8. Normal hearing bilaterally.

Lose any one of these and a forward head posture may occur.

The two types of FHP we see include one with the atlas migrating forward with increased cervical flexion and occipital protraction.

Forward-Head-Posture

 

And one in which the atlas migrates backward on the occiput in which excessive upper cervical flexion coupled with lower cervical/upper thoracic hyperextension.

images

With the former’s case, these individuals have a harder time feeling posterior teeth; a loss of frontal plane. When one loses frontal plane, the individual must attempt to increase anterior guidance via extension. Strategies used to do this include tongue thrusting, bruxism, fingernail biting, mouth breathing, clenching, etc. These strategies are protective in nature as they limit potential stress at the TMJ and OA.

Most of the latter include your bilaterally extended individuals. They retrude the atlas to significantly increase cervical stability. This hyperstability allows for dominant performance in the sagittal plane. These individuals may need more visual interventions.

 

She’s a Wise Woman

Dr. Heidi Wise gave one of my favorite presentations of the symposium. She discussed vision’s role in extension-driven individuals.

Vision is the most dominant sensory modality, as it has the ability to override all other senses to redirect attention. To me, this is why vision is such a powerful way to get someone neutral.

Redirection of attention through the visual system occurs through saccades. These eye movements occur 85% of the time our eyes are being used. This is how the visual system detects a salient stimulus.

If visual processes hold someone in an extension pattern, it may become extremely difficult to near-impossible to overcome.

Here is how we start thinking a visual process may be promoting an extension pattern:

  • Those who cannot inhibit extension with traditional floor-up activity.
  • Late-onset (past puberty) or severe near-sightedness.
  • People with extremely good eyesight.
  • Folks who over-focus on objects straight ahead (people who stare).
  • People who walk with purpose (makes me think of my mom in the mall!).
  • High-energy.
Probably more than just a vision patient.
Probably more than just a vision patient.

If someone over focuses (read: nearsighted), eye exploration is minimized. It becomes much harder to notice change, or salience. This is how the visual system can keep someone stuck in a stress response.

What is needed to see close?

  • Increases in acetylcholine and norepinephrine.
  • Reflexive increase in neck/head muscle tension. More so if one must strain to see.

Do this too long, and we can see unfavorable autonomic, visual, and neuromuscular stress.

And guess what visual field research is showing we better attune to? The right side; more specifically, the right upper visual field.

The PRI goal? We want to restore ambient vision in these individuals to process three planes of visual motion.

Here were some of Heidi’s recommendations for how to do so.

  1. Take breaks from a task to move.
  2. Be aware of surroundings on both sides without looking when walking.
  3. Walk slower than usual.
  4. Look around using your eyes independent of your head.
  5. If nearsighted, take glasses off occasionally and “be OK” with things far away being blurry. Don’t strain to see well.
  6. Have top of computer screens at about eye level. Look far from the screen as often as possible.
  7. Close eyes and visualize a large open area that makes you calm.
  8. Minimize time on small, close screens and keep object far from eyes.
  9. Read books over e-readers and keep the book as far away as visually comfortable.
  10. Emphasize peripheral awareness before and after high attention tasks.
  11. Change variable such as sounds or environment during high attention tasks.
  12. Get away from looking in the mirror at movements.
  13. Change lightbulbs to natural daylight.
heidi
And Heidi’s as well

 

Mental Muscle

Dr. Todd Stull provided a lot of neat neuroscience nuggests.

  • Glia purges our brain of waste during sleep.
  • Strongest memories are tied to emotions; more negative than positive.
  • If the limbic system is too active (such as in a threatening environment), prefrontal cortex activity goes way down. You can’t learn as well.
  • Cranial nerves are extremely important in social interaction. Nonverbal cues from these areas can unconsciously affect autonomics.
  • During adolescence (12-25) the right side of the brain and limbic system develop faster than the left and neocortex. This lateralization is why this time period can be so emotion-driven.
  • Face to face interaction is needed to cultivate the nervous system. This is the problem with social media and texting.
  • Dopamine pathways are very active during adolescence; it’s one of the reasons addictions start during this time.
  • Feelings of being overwhelmed are 6 times more common in those who have had concussions.
  • Rehearse making mistakes and how you will come out of them.

He also provided some great patient interaction nuggets that I hope to liberally steal.

  • Keep your eyes on the individual and tell them “it’s great to see you here.”
  • If you are not doing well on a given day – “I don’t feel good today but we’re going to have a good session.”
  • If you are at odds with a patient – “We’ve seemed to come to a roadblock. Would you agree?”
Ya don't say?
Ya don’t say?

 

Optimizing Mindsets 

My big takeaway from psychologist Dr. Tracy Heller’s talk was mindfulness.

Mindfulness is something I am hoping to get more into in the future. She defines it as being aware of your thoughts, emotions, physical sensations, and actions in the present moment without judging or criticizing yourself or your experience.

It’s a big deal to have this capability. Practicing mindfulness has been shown to reduced cortisol, stress, pain, depression, and anxiety; while also improving memory, sleep, and cognitive function.

The way we build mindfulness is basically letting go. I like the analogy that I heard while using Headspace (a great app if you haven’t used it). Imagine your thoughts and feelings as cars in traffic. Your goal is to just watch the cars pass by, not chase them. You want to be present in the moment, as we want in most of life.

And if you can do this in LA you'll put most Tibetan monks to shame.
And if you can do this in LA you’ll put most Tibetan monks to shame.

One option of practicing this is resonant frequency breathing, in which we perform 4.5-7 breath cycles per minute. Let the body breathe on it’s own and let the air come in; using terms such as “let,” “allow,” and “permit.” These are cues I have been using much more with patients and has made a big difference.

 

Dad’s Part

This was easily my favorite part of the symposium (I may be biased since my Dad gave this talk). Bill Hartman blew it out of the park teaching us how PRI applies at the highest level of performance.

The rules change in the performance realm because the patterns are incredibly powerful, effective, and efficient. In some cases we may want them. A perfect example that Bill gave: Usain Bolt

Rarely does he cross midline when he runs, making him the fastest runner on one leg. Do we want to change that? Probably not.

Performance does not equal health. Gymnasts for example, may need to create pathology to perform at a high level. Some people must utilize passive elements to produce greater outcomes. Usain Bolt runs on one leg. Everyone is a case-by-case basis. N=1 forever.

What must occur in the performance and health realm is stress management. Acute stressors with recovery make us antifragile; prolonged stressors reduce variability as an allostatic adaptation.

If one must constantly perform at a very high level, where will they be on this stress dichotomy? Prolonged stressors = reduced variability, sympathetic dominance, and system extension.

Variability helps us anticipate demand. It helps us become better able to cope with specific environments and recover movement function. The only way we can know if movement variability is present is through assessing the musculoskeletal system

 “The state of the musculoskeletal system is the other end of the brain” ~ Bill Hartman

If stressed or threatened, body systems use default reflexive mechanisms to combat threat. The brainstem is much faster than the cortex. As a consequence, variability can be lost.

Attaining increased prefrontal cortex activity allows us to inhibit our default response and increase variability. That’s why mindfulness increases HRV, and that’s why a 90/90 hip lift can alter body position.

And why juggling gets Bill neutral. Chainsaws preferred.
And why juggling gets Bill neutral. Chainsaws preferred.

To better manage stress, we must train. Training is a progressive desensitization of threatening input to allow an athlete to perform at adaptive potential with optimal variability and without fatigue.

The higher performance level required, the more difficult it becomes to get neutral. This is what happens during functional overreaching. You gain higher performance output during this timeframe because the sympathetic nervous system and HPA axis are on overdrive.

Applying Bill’s principles along the training and rehab continuum, rehab requires neutrality and variability to rebuild a failed stress tolerance. The amount needed in performance realm will depend on how (in)variant one’s sport is.

The Wild World of Combat

Dallas Wood and Zach Nott work with in a military population, and it was fascinating showing how they mitigate the extension necessary for their clientele to perform. They guys collect a lot of data, and the fun factoid was that about 80-90% of their individuals are PEC and bilateral BC (surprise surprise).

They showed us a very cool auditory case. They had a dude with a PEC/BBC presentation with a history of ear trauma and tinnitus. When they blocked his left ear the gentleman was completely neutral.

A viable treatment in probably more cases than you'd think.
A viable treatment in probably more cases than you’d think.

Treatment underwent reducing the tinnitus by implementing a hearing aid that uses various white/pink noises to slowly reduce tinnitus. Not sure exactly how it works, but this was exciting to hear about (ha). I look forward to learning where PRI takes auditory integration.

 

C’est Fini

 So there you have it. I already signed up for next year’s symposium because this one was so much fun. I look forward to more of the consistently fantastic content that PRI provides. Learn on!