[iframe style=”border:none” src=”//html5-player.libsyn.com/embed/episode/id/5716224/height/100/width/480/thumbnail/no/render-playlist/no/theme/custom/tdest_id/568557/custom-color/#87A93A” height=”100″ width=”480″ scrolling=”no” allowfullscreen webkitallowfullscreen mozallowfullscreen oallowfullscreen msallowfullscreen]
Here’s what we talked about:
- What makes getting patients to do their home exercises challenging.
- Strategies I implement to increase adherence.
- How I determine when sagittal plane control is adequate.
- What I think PT will be like 25 years from now.
What Were We Talking About Again?
If there is one thing I’ve struggled with over the years, it’s long term retention.
Though remembering course materials has had it’s challenges, the struggle is worse with books.
Overconsumption was part of the problem. Trying to read faster, and across multiple unrelated books caused more detriment than use. Much as our attention spans can be overstimulated by abundant information on the internet, so to can we suffer this fate with reading. There are a lot of books after all.
While narrowing my reading focus has helped quite a bit, improving my reading strategy was equally important.
I remember one summer I made it my goal to learn how to shuffle cards. We played A LOT of cards on my family vacations, and I was tired of having to use the automatic shuffler or having someone else shuffle for me at the family card game.
It was time to become a man, damnit!
I shuffled anytime I had some free time during the day; which back when I was a kid led to multiple bouts of daily shuffling.
By the end of the summer, I was unconscious with shuffling, and still am to this day.
Frequent, quality repetitions at any task will likely lead to improvement. Learning material is no different, we must just foster an environment of multiple exposures to said material.
Here’s my latest attempt at doing so. Continue reading “The 6-Step Method to Reading the Shit Out of Books”
Pelvises Were Restored
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 the solution to open the system.
Pausing after an exhalation gives diaphragms time to ascend. Diaphragmatic ascension maximizes the zone of apposition (ZOA). The better ZOA we have, the less accessory musculature needed to take an adequate breath.
The two important ZOAs needed in this course are at the thoracic and pelvic diaphragms. We want to build synchronicity between these two diaphragms.
The way we do that is through the pelvic inlet.
The inlet links and adequately positions these two diaphragms via internal obliques and transversus abdominis (IO/TA).
To determine how this occurs, we must look at how breathing affects musculature.
This part here was a huge lightbulb moment for me. Muscle lengthening correlates with inhalation, and muscle shortening correlates with exhalation. So to create a stretch in areas you wish to lengthen, you may want to inhale, and to increase muscle contractility, you may with to exhale.
[Note: This is one reason in lifting exhalation is during the concentric phase and inhalation is during the eccentric phase?]
Now lets apply this concept to the pelvic inlet in an extended system. Let’s say the left innominate is forward (a LAIC pattern). My left IO/TA on would be eccentrically lengthened and in a state of inhalation. The left thoracic and pelvic diaphragms would be tonically active and form a v-shape.
This dyssynchrony explains why certain pelvic and thoracic tests correlate. The LAIC pattern suggests that I would not be able to adduct my left hip.
At the pelvis, this would occur because I have a “long” left anterior outlet and “short” posterior outlet.
The outlet and the thorax reflect one another. In this case, my anterior outlet is equivalent to the ipsilateral anterior chest wall and my posterior outlet is equivalent to the posterior mediastinum.
Guess what the tests will look like? I will have good left apical expansion and limited left posterior mediastinum expansion. I can’t adduct my left thorax or abduct my right thorax, much like I can’t adduct my left hip or abduct my right hip. These tests look at the same thing the pelvic tests do.
The Definitive Word on PRI Squatting
We can look at one’s ability to actively synchronize the thoracic and pelvic diaphragms by one’s ability to squat.
The functional squat test is an excellent way to show if one is capable of maximal pelvic diaphragm ascension and can shut off extensor tone. It also is a test to see if one has a patho-compensatory pelvic floor; for if you can squat but can’t adduct your hips, you gotz problems.
Here is what the functional squat test is not: a position to go under load in the weight room.
The above was straight out of Lori’s mouth. So to all the people who talk smack about the PRI squat, your answer is above. It’s not looking at the same thing as a max effort back squat.
Here’s how to test it.
Sitting is Hahhhd
In PRI land, sitting is the most challenging position to be in.
Why? Because there are less points which one can reference. Sitting unsupported requires proprioception exclusively on your ischial tuberosities. Success here relies on alternating and reciprocal muscle recruitment. If I don’t have this, I will extend.
Some Quick Postural Eyes
Lori is a great at predicting how dynamic movements will look on the table. Here were a couple things that stood out to me in this regard, as well as a couple other random things.
- Leg whipping means an individual likely has a femur stuck in adduction.
- Patho-compensatory people usually have more narrow hips. Could possibly be more common in males for this reason.
- People who lean to one side in gait need a glute med.
- If one cramps during an exercise, think inhibition. We’d rather shaking.
- Glute med is the needed ligamentous muscle if a hip subluxes laterally.
- Furniture is made to fit people who are 5’8.
- Hard orthotics = overrated. We want a soft heel cup and arch to be used proprioceptively.
- “I like to refer to myself as your coach.”
- “You can’t work the same muscle in a different position and expect the same outcome.”
- “You know I’m going to have to spend some time on this little booger.”
- “If you want to give more pelvic instability stretch hamstrings.”
- “She trusts me and I make her shake which is all good.”
- “PECs cannot breathe to the high moon.”
- “Getting neutral is not treatment.”
- “Her back needs to go on a holiday.”
- “Run with ribs.”
- “When you go run, run.”
- “We like extension, just not 24 hours a day 7 days a week.”
- “If your patients cannot breathe correctly, don’t do a PRI activity. They will fail.”
- “Not everyone needs a pair of glasses. Some people need a diaphragm.”
- “I’m not a comedian. I’m here to teach you.”
- “We’re [the clinician] not in control. We’re just invited to the party.”
- “I get excited when I feel my right glute max burn.”
- “You normal human being you.”
We are hosting several courses at my clinic this year, and we would love to have you, the readers, attend.
The three courses that East Valley Spine and Sports will be hosting are all excellent courses. I have taken two of these classes prior, and the third I have taken a prior rendition of. And let me tell you, these courses are boss.
Aside from us bringing some excellent content, you will also have the opportunity to hang out with a good group of people, and imbibe in some good beverages with me.
Here is what we are bringing.
PRI Pelvis Restoration: March 28th-29th
I took this course a little over a year ago (read the review here) and I am very excited to be learning from Lori again. She presents this very complex material in a systematic and understandable fashion.
Most importantly, she’s funny!
Signup for the course here.
ISPI Therapeutic Neuroscience Education: Educating Patients about Pain: June 6th-7th
Adriaan Louw is one of the best speakers I have heard, and the material is priceless (read my review here).
This course gives several practical insights as well as easy-to-learn neuroscience education that will help you become adept and educating patients on pain.
Signup for the course here.
ISPI Neurodynamics: The Bodies Living Alarm: October 17th-18th
I took a version of this class when Adriaan spoke for the NOI group, and I am excited to see what tweaks have been made since. This time we are bring Louie Puentedura in to teach the class. I am excited to hear his perspective, as I have never seen him talk. Adriaan speaks highly of him, so he’s okay in my book!
Signup for the course here.
We look forward to seeing you. Come learn, laugh, and party with us in lovely AZ.
Third Time’s a Charm
Mike Cantrell was in my neighborhood to teach Myokinematic Restoration by the folks at PRI.
And I couldn’t resist.
This is the third time I have taken this course, a course I feel I know like the back of my hand, yet Mike gave me several clinical gems that I want to share with y’all.
This post is going to be a quick one. If you want a little more depth, take a look at my previous myokin posts (See James Anderson and Jen Poulin). Or better yet, take a PRI course for cryin’ out loud.
Hip Extension, We Need That Yo.
Sagittal plane is your first piece needed to create triplanar activity. Since this is a lumbopelvic course, we look at getting hip extension as high priority.
If I am unable to extend my hip, here’s what I could try to use to do it:
- SI joint compression
- Anterior hip laxity
- Gastrocnemius and soleus.
We use two tests to see if we have hip extension: adduction drop (modified ober’s test) and extension drop (Thomas test).
The adduction drop will look at your capacity to get into the sagittal and frontal plane, and the extension drop test will look at your anterior hip ligamentous integrity.
A positive extension drop is a good thing if you are in the LAIC pattern. It means you didn’t overstretch your iliofemoral and pubofemoral ligaments. Well done! The reason why this test is not a hip flexor length test has to do with the femur’s position. In the pattern, the femur is positioned in a state of internal orientation secondary to an anteriorly tipped and forwardly rotated pelvis.
Due to this orientation, the femur must be externally rotated during performance of an extension drop test. This would put the psoas on slack. If you still have a positive test, then we know the anterior hip capsule is intact because that’s the only thing holding the hip up.
We spent a good portion of the day learning about gastrocs. In the LAIC pattern, the right gastroc runs the show as a hip extender AND hip external rotator.
The slight inversion action that the gastrocneumius performs helps pick up the transverse plane slack that the right glute max is malpositioned to do so. This is why the right calf is usually larger than the left.
Your calves run the show if:
- There is an early heel rise in gait
- There is a heel whip
Adduction Lift Epiphany
If you don’t know what the Hruska Adduction lift test (HAdLT) is, read THE Jen Poulin’s myokin piece then come back to this.
Or just watch the test.
This test’s pinnacle is the 5/5, to which gives us ground to become alternating and reciprocal warriors.
Just because you can hit 5/5 on both sides does not mean you can alternate well.
I was a prime example in class. Mike had me demonstrate my HAdLT in class, to which I easily hit 5’s on both sides.
Despite my quest towards neutrality, I have not been able to keep good thorax and neck positioning. Thanks wisdom teeth.
So Mike checked my right shoulder internal rotation, to which I had about 70 degrees. Way better than the previous 10 or so degrees I started at.
Then Mike had me perform the left HAdLT, which pushed me into my right hip.
Shoulder internal rotation worsened to 30 degrees.
He then pushed me into my left hip with the HAdLT.
Shoulder internal rotation now 90 degrees.
Even though I can crush the lift test, I do not alternate well because I lose position at other areas.
To truly be an alternating and reciprocal warrior, one must be able to perform alternating activities without losing position anywhere in the body.
Why Can’t I Swing my Right Arm?
In many folks with a LAIC/RBC pattern, you will notice that there is minimal right arm swing. You would think that the right arm would be activity secondary to right lateralization and hemisphere dominance. Not necessarily so though.
Arm swing is dependent on trunk rotation. If the trunk can rotate, then the arms can swing.
In the pattern, it becomes very difficult to rotate the trunk to the right, which mean there is no need for right upper extremity extension. So how about instead we just plaster the arm the side? Not a bad idea.
Crazy Good Cues
To close, Mike is a cueing machine. I picked up three new favorites that we’ve been playing around quite a bit in the clinic.
- Press heels down on a chair to decrease TFL. Don’t use a ball because the TFL will attempt to adduct the femur via internal rotation. Then slowly add the ball.
- Sigh upon exhalation if you have a patient who is rectus-dominant.
- Plantarflex the first big toe to feel the left IC adductor in standing.
- “Orthopedic symptoms are the result of bad neurology.”
- “Good posture compromises respiratory dynamics.”
- “Think before you stretch.”
- “Stretching is the equivalent of kicking a horse while pulling on the reins.”
- “99% of righties have a left thing.”
- “Doesn’t matter what the diagnosis is.”
- “Give me sagittal or give me death.”
- “Most strength deficits are motor control deficits.”
- “Total arc depends on what moment in gait you are in.”
- “My goal is to take that exercise away from you.”
And That’s a Wrap
It’s that time of the year that we get to look back and reflect and what posts killed it (and which bombed).
It seems as though my fine fans be on a pain science kick this year, and rightfully so. It’s some of the best stuff on the PT market right now. It’s definitely a topic I hope to write about more in the coming year, and one I will be speaking on at this year’s PRC conference.
But without further ado, here are the top 10 posts of 2014.
Going through the treatment process as a patient has really upped my game in terms of knowing when to integrate with my patients. It has also been a life-changing experience for my health and well-being. Learn how they did it for me.
So much fine tuning occured the second time around. I love how Jen acknowledged the primitive reflex origin of the patterns, as well as fine tuning both lift tests. She’s an excellent instructor (and fun to party with)!
The start of my alternating and reciprocal saga. Made for one of the most fascinating evaluations I have ever experienced. Ron Hruska is otherworldly.
I love a good foundational course taught by the Ronimal. You always get a few easter eggs that allude to higher level courses and concepts. A must-take course.
One of the most powerful and humbling courses I have ever been to. Ron goes all out on this course, as it is his baby. What dental integration can do to a system under threat is a concept that I hope is further explored in medicine. We can’t do it alone folks.
This post marked a shift in my thought process and a realization of the possibilities that an integrated health system can accomplish. I have high hopes for our profession, and feel excited that an original post had so many views.
It seems that with each PRI course you take you go another layer down the rabbit hole. Pelvis is a great course to link up Myokin and Respiration; especially with Lori and Jesse at the helm.
Couple the best manual therapy explanation I have come across and a gentle technique and you get a rock solid course. The only downside is that now Diane has tarnished any other manual therapy course for me, as I can’t rationalize any other explanatory model given.
Fine by me.
I love Adriaan’s practical application of pain education to patients, and he is one of the best speakers in the biz. There’s a reason why I am hosting him again next year.
A great neuroscience course, a great practical course, and getting to learn from a PT legend? Sign me up.
And that marks the last post of 2014. Which were your favorites? Which are you hatin’ on? Comment below and let’s hope to even better content in 2015!
Six Months Later
I have developed a beautiful squat, am noticing less back issues when I lift, and just generally feel mo’ betta. I also have zero fatigue when reading or on a computer screen.
That said, I was still getting some right neck tension and felt that my reading comprehension was not as good as it was.
I was accommodating to both my orthotics, so I thought my next trip to Lincoln would be a good time to follow-up.
If Youz Ain’t Assessin’ You Guessin’
Came through the door after a long flight and minimal sleep, and surprised even myself.
Without any orthotics, I was neutral at my pelvis and thorax, but still had some left cervical axial rotation and right OA sidebending restrictions.
I was also lacking the capacity to perform mandibular lateral trusion without kicking in my SCMs. The reason why I don’t have access to my pterygoids for this movement?
Those DAMN wisdom teeth.
My wisdom teeth essentially alter pterygoid position and reduce my mandible’s capacity to move. When I protrude, I have to extend my OA joint and utilize a forward head posture to complete the movement.
The same thing occurs with lateral trusion. When I attempt the movement, the bony block limits my pterygoids from performing the action. SCMs, in particular the right, try to pick up the slack.
From a visual standpoint, I was sitting pretty. I didn’t really have much trouble with far vision, and when Heidi checked my close vision my eyes were working symmetrically.
The fix for me is still wisdom teeth extraction (which is happening in October of next year), but was there anything else that could be done until then?
“There’s one more thing we can try.” ~ Ron Hruska
I see Ron place a pole out in the PRI vision hallway and he has me stand and stare on the right corner of a doorway.
“How far away does that appear?”
I said it was about 6 feet away.
I did the same exact thing on the left side of the door, only this time the pole appeared a couple feet farther away.
Having that slight depth perception asymmetry was my last saving grace before teeth extraction, as this was how we were going to give me a little bit more frontal plane.
They fit me with some very lightly prescribed lenses and focus on evening out my depth perception. The way that I do this is by activating my left SCM with right cervical rotation and then moving my eyes to the left. I also do the reverse. This activity is to be done on either side of a doorway so I alternate from looking at close and far space.
Just doing this exercise a couple times a day has already quieted my right neck down quite a bit, so I am hopeful that this will carry me the next several months until surgery.
I will now be doing extra-ocular muscle day at the gym in place of back and bi’s.
In terms of reading, we tried some evened out lenses but I couldn’t really tell a difference in terms of comprehension. What actually made the largest difference for me was taking my splint out and reading. Ron said that the splint is used to create movement for me, so was probably not necessary when I read. I just have to remind myself to contact my teeth every so often when I am reading.
The Game Plan
Aside from the little activities above, I am discharged from PRI vision. I only need to come back if I get some visual changes after I get my wisdom teeth out. From here on out it’s all about getting my EOMs jacked, alternating activity, and wearing my splint less.
Can’t wait for October.
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.
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.
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.
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.
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.
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? 🙂
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.
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.
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.
- 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.
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.
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.
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.
- “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.”