Challenges of Home Exercise Execution, Do You Really Have Sagittal Plane? and PT in 25 Years

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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.

Check out this episode!

The 6-Step Method to Reading the Shit Out of Books

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.

member-berries-t-shirts-women-s-t-shirt
My next strategy if this doesn’t work.

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.

download copy
One might say

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”

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.

There's a few things going on here.
There’s a few things going on here.

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.

Not when you can utilize system flexion
Not when you can utilize system flexion

Synchronized Diaphragms

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.

Dat inlet yo
Dat inlet yo

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.

I call this superior gluteal migration
I call this superior gluteal migration

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.

Only the tests have changed.
Only the tests have changed.

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.

Done.

It's not that you don't know how to squat. It's that you don't know how to poop.
It’s not that you don’t know how to squat. It’s that you don’t know how to poop.

Here’s how to test it.

 

Sitting is Hahhhd

In PRI land, sitting is the most challenging position to be in.

Yeah uh no.
Yeah uh no.

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.

Lori-isms 

  • “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.”
What if the hurricane was named Lori?
What if the hurricane was named Lori?

Come Hang With Me: Courses At My Clinic

Dear Readership

 We are hosting several courses at my clinic this year, and we would love to have you, the readers, attend.

We...The readership
We…The readers

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.

Class is next, the course is nice, and we can talk neuro all night.
Class is next, the course is nice, and we can talk neuro all night.

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!

Thank you, she'll be here two days.
Thank you, she’ll be here two days.

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).

10% chance Adriaan will wear this outfit at the course. 100% chance the class will be stellar.
10% chance Adriaan will wear this outfit at the course. 100% chance the class will be stellar.

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!

And it's not an easy read.
And it’s not an easy read.

Signup for the course here.

 

We look forward to seeing you. Come learn, laugh, and party with us in lovely AZ.

Course Notes: Cantrell’s Myokin Reflections

Third Time’s a Charm

Mike Cantrell was in my neighborhood to teach Myokinematic Restoration by the folks at PRI.

And it was a beautiful day in the neighborhood
And it was a beautiful day in the neighborhood

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:

  • Back
  • 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)

Exhibit A
Exhibit A

and extension drop (Thomas test).

Exhibit B
Exhibit B

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.

And now just plain ol' Xzibit.
And now just plain ol’ Xzibit.

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.

Heeeeeyyy...Adduction drop until the femurs fall off.
Heeeeeyyy…Adduction drop until the femurs fall off.

Dem Cows

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
Coming to a PT clinic near you.
Coming to a PT clinic near you.

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.

The Alternate Warrior
The Alternate Warrior

However….

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.

Mike: “Showoff.”

Despite my quest towards neutrality, I have not been able to keep good thorax and neck positioning. Thanks wisdom teeth.

Dick
Jerk

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.

Bad idea.
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.

Cantrellisms

  • “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.”
How I envision Mike's first Cervical Revolution course.
How I envision Mike’s first Cervical Revolution course.

The Post Wonderful Time of the Year: 2014 Edition

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.

10. Treatment at the Hruska Clinic: PRI Dentistry and Vision

Lift scores 6/5 with the Bane mask on. #alternatingandreciprocalwarrior
Lift scores 6/5 with the Bane mask on. #alternatingandreciprocalwarrior

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.

9. Course Notes: THE Jen Poulin’s Myokinematic Restoration

She's a myokinematic beast!
She’s a myokinematic beast!

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)!

8. Treatment at the Hruska Clinic: Initial Evaluation

Producing so much saliva
Producing so much saliva

The start of my alternating and reciprocal saga. Made for one of the most fascinating evaluations I have ever experienced. Ron Hruska is otherworldly.

7. Course Notes: PRI Postural Respiration

Chiari malformation waiting to happen.
Chiari malformation waiting to happen.

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.

6. Course Notes: PRI Craniocervical Mandibular Restoration

Ron looks even better in person with the meat suit.
Ron looks even better in person with the meat suit.

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.

5. The End of Pain

Still verklempt by the overwhelmingly positive response.
Still verklempt by the overwhelmingly positive response.

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.

4. Course Notes: PRI Pelvis Restoration

A good group to learn from and with.
A good group to learn from and with.

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.

3. Course Notes: Dermoneuromodulation

Diane is bullseye with her neuroscience.
Diane is bullseye with her neuroscience.

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.

2. Course Notes: Therapeutic Neuroscience Education

Stayed hungry to learn ever since this course.
Stayed hungry to learn ever since this course.

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.

1. Course Notes: Explain Pain

A legend
A legend

A great neuroscience course, a great practical course, and getting to learn from a PT legend? Sign me up.

Game Over!

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!

496d30611f94277eee71b80e3cd0f24cb9

Hruska Clinic II: The Follow-up

Six Months Later

I have come pretty far in my journey since initially being treated at the Hruska Clinic (see day one, two, and three).

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.

Just wait until you hear my Jabba the Hutt impression
Just wait until you hear my Jabba the Hutt impression

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.

images

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

Ron was on the mic
Ron was on the mic

Vision 201

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.

 I felt like Jesse Ventura when Arnold lifted the car up in Predator.

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.

So many compliments on my lateral rectus striations.
So many compliments on my lateral rectus striations.

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.

Never thought I would look forward to having surgery, but hey whatever.
Never thought I would look forward to having surgery, but hey whatever.

A Fly on the Wall of the Hruska Clinic

The Saga Continues

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

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

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

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

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

Plus, summer forevaaaaaaaaaaaahhhhh!!!!!!

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

And their operation is a beautiful thing.

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

The General Feel

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

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

It screams parasympathetic.

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

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

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

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

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

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

The Session

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

Almost as refreshing.
Almost as refreshing.

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

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

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

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

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

 

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

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

Helpful Tidbits

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

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

 I Have a Vision

 You might be a vision patient if…

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

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

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

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

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

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

Other tips:

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

 

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

All Bite, no Bark

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

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

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

Other neat things I picked up:

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

Testing Tips and Tricks

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

Nonmanual Tips and Tricks

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

 

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

Manual Tips and Tricks

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

Clinic Quotes

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

Treatment at the Hruska Clinic: The Finishing Touches

For part 1, click here.

For part 2, click here.

A Low Key Day 3

 Day three consisted mostly of putting the finishing touches on my quest toward neutrality.

The morning began by tweaking my gelb splint so I was getting even contact on both sides. This way I would be ensured to not have an asymmetrical bite.

I put a pair of trial lenses that fit my PRI prescription, and grinding commenced. We finished with this:

 

Complete with official zaccupples.com saliva
Complete with official zaccupples.com saliva

Once the splint was done, I had a final meeting with Ron to go over my exercise program.

I was placed into phase one visual training with two pairs of glasses. My training glasses were to be used when I lift weights, perform my exercises, walk around, etc. I could wear these for up to 30 minutes at a time; making sure I maximize my visual awareness of the environment.

While I was wearing these glasses, I was to be keen on finding and feeling my heels; especially when I turn my head. The glasses would help me find the floor, as well as help my eyes work together and independently from my neck.

My second pair of glasses was to be used while performing any activities within arms reach. This pair helps my eyes converge better and promote less eye fatigue.

Ron gave me several phase I vision activities as well as a few others. His main objectives were to get my eyes to move independent of my neck. We also wanted to create thoracic rotation on my rock-solid hip alternating capacity.

Here was my list:

The first activity helped with differentiating eye and neck movements.

The next activity was more alternating reaching in left stance; key is to keep eyes on left arm.

This beast below used a mirror to help me visualize doing the exact opposite pattern that I was trying to create; more visual tricks.

This next exercise utilized viewing the environment while using my alternating skillz

And here we have another very good alternating thoracic activity.

The Neutral Lifestyle

 I’ve had my splint for a month, reading glasses for 3 weeks, and consistently using the training glasses for 2 weeks now.

In just that short amount of time I’ve noticed quite a few changes. Granted, there could be many influences as to why these things have occurred, but I’ve tried to minimize as few variables as possible.

I've tried so hard even.
I’ve tried so hard even.

Training/Fitness

This area is where I’ve noticed the most changes. My recent program block for the past couple months or so has been very aerobic based. I lift weight 3 times per week at mostly tempo style. The other 2-3 days I train consists of one day playing basketball for cardiac output and either high intensity continuous training on my bike and/or tempo intervals with a jump rope or sled.

Before glasses (BG), I was measuring my heart rate variability (HRV) and resting heart rate (RHR). These numbers have not budged much with the month or two that I have been training like this. But after glasses (AG), I have noticed general trends of my HRV being higher and my RHR lower.

Exhibit A
Exhibit A. Slacked on measuring for a while, but was not budging from 3-4/2014

The HRV changes are what impressed me the most, as I have had many more outside stressors occurring in this time period. So despite being in a higher stress environment, my HRV climbs.

In the weight room itself, the load I have been lifting has generally tanked. I have lost strength in many of the lifts that I was doing, yet I’m actually feeling more work occurring in the areas that ought to be working. My neck and back seem to be kicking in much less. This was a pleasant surprise. I also seem to get less tired during the aerobic stuff I have been doing. Again, these changes could be due to time, but most of these reports have not changed in the few months that my aerobic training has occured.

The craziest change yet? Without performing any true “jump training,” I was able to easily grab the rim on a 10-foot basketball hoop for the first time since high school.

The Arizona POTS population shudders, my fiancee just shakes her head.
The Arizona POTS population trembles.

I can also now perform a full deep squat unsupported, which is something I have been practicing since January. I was unable to do this until the second week AG.

Regular Life Stuff

 Many more changes have occurred to me with just regular life stuff. I generally feel much more rested after sleeping, even if I get less hours than I am normally accustomed to. I also don’t seem to get as many afternoon lulls as I used to.

Reading. Oh My lanta. What a huge difference. I am retaining quite a bit more of what I read, and find that I do not get eye fatigue. Like, at all. Even if I am on the computer for a very long time.

Neck tension has been variable. I notice quite a bit less when I am reading, but I still tend to feel it if I am away from my orthotics, driving, or extremely stressed. The frequency this tension is present is quite a bit less.

I do still get some jaw clicking with opening, but the gelb splint seems to decrease this frequency quite a bit.

Overall, I generally just feel good.

I knew that I would.
I knew that I would.

Why Neutral

 I have had a lot of people ask me why I went through this process, especially if I do not have pain. Curiosity and need for completion drove me there, but I left with so much more than I thought I would ever get.

The nervous system craves three things: movement, space, and bloodflow. As a PEC with limited mobility in every plane, my system was not getting space. Less space increases stress to my nervous system, which may or may not have led to many possible outputs.

Pain is only one of many outputs that a system under threat could produce. Perhaps an output could be hypertension, dizziness, fatigue, heartburn, decreased attention, inability to learn, constipation, anxiety, depression, etc.

Maybe even a decreased vertical jump could be an output in response to system threat.

Likely anything that has a large contributing factor from our normal stress response could be affected favorably by decreasing system load through achieving neutrality.

Possibly affecting everything this guy has written.
Possibly affecting everything this guy has written.

It is here that I feel PRI is leagues beyond any other treatment methodology, and could potentially have impacts beyond pain; something many conventional PT methods may not always address. It is not because these methods are bad or do not work, but it is because they are only addressing a few pieces of the human system.

PRI is the only framework I have seen that addresses and explains most completely how the human being functions under threat.

Does that mean PRI is going to cure everyone’s problems? Probably not. Some conditions could be too far gone, some may have causes/effects beyond our normal stress response.

You cannot know if something will be helped or harmed by PRI until you take the autonomic nervous system out of the equation. And that is how I believe PRI works.

52557302

 

Treatment at the Hruska Clinic: PRI Dentistry and Vision

For part 1, click here

For part 3, click here

Jaws will Drop

 I’m in the dentist chair, The room slowly get darker and darker. I feel my mouth open, and I wasn’t sure what would happen next.

Then Dr. Schnell places the necessary goup in my mouth to get an impression for my splint. I bite, and out comes the finish product.

You live to see another day. Bastards!
You live to see another day. Bastards!

Before the impression was taken, Ron came in and explained what he was hoping to accomplish. He wanted to fit me for a gelb splint to give my tongue some space to move in my crowded mouth. This splint would also help bring my mandible forward.

Dr. Schnell: “Is he neutral right now?”

Ron: [throws a towel over my eyes and sets my neck in a lordosis] “Now he is.”

And with that, the above sequence occurred and I was ready for vision.

Don't forget to bring a towel when you do your PRI exercises.
Don’t forget to bring a towel when you do your PRI exercises.

I couldn’t leave the room without that overarching reminder Ron gave me:

Ron: “Margo, if this was your son, what would you do with those wisdom teeth?”

Dr. Schnell: “I’d have them pulled.”

Yikes!

An Eye Opening Experience

 It was so much fun watching Ron and Heidi teach together, that I could only imagine what it was like seeing them treat.

They did not disappoint.

My session was getting videotaped for their marketing department, so I again told them my story. It ought to end up on the Internet sometime, so stay tuned for that!

They began the session by showing some of my mobility limitations:

  • HG IR: 20-30 degrees bilaterally, if that
  • HG horizontal abduction: 15 degrees bilaterally.
  • SLR: 30-40 degrees bilaterally.
  • Adduction drop/obers: + bilaterally.
  • Passive hip abduction: 30ish degrees bilaterally.
  • Cervical axial rotation: 10 degrees left.
  • Cervical sidebending: limited right.
Only known extension I have.
Only known extension I have.

The intervention consisted of me trying different lenses, walking, and retesting.

Each lens gave the environment and me a completely different feel. Some lenses made me shift most of my bodyweight to the left, some would make me feel shorter, and some would tighten my neck or my back.

Almost every time they gave me a different lens my tests would change. HG IR would go to 70 degrees one time, then 90, then back to 70. Straight leg raise steadily increased until it got to 90; crazy changes just with glasses.

Ron: “See that’s not fair, she [Heidi] knows more than me.”

The big tests for them, regarding when they knew they “had me,” were the standing global-orbital rotation (SGOR) and standing cranial tilt test (SCT). The former looks at transverse plane activity, and the latter frontal.

The SGOR came fairly quickly from what I remember. Many lenses had a hard time getting me to my left heel, but eventually the right pick was found.

The SCT was a little different beast. I was fairly solid from the waist down, but once neck movements were into play I had a much harder time maintaining my balance; at least without the glasses on. Once they found me the right pair, I was golden. Fully neutral and near-master of the frontal and transverse plane.

Time to get mobile.
Time to get mobile.

The Hardest Vision Test Yet

 Heidi and Ron were pleased with the choices made for my training glasses, but Heidi’s largest worry was having me maintain neutrality while I read. A bulk of my day consists of documenting at the computer, writing, and reading books/journal articles. She knew that I needed to be rock-solid there.

I had my first vision exam a month or so before I trekked to Lincoln, and my results were “unremarkable” to my optometrist. I am slightly hyperopic in my right eye (+0.50 for you optometry nerds) and myopic (-0.25) with a slight astigmatism in my left eye. My clarity is 20/20, so I can see fine, but Heidi felt that I had some marked left eye dominance. The above measures are a normal in the PRI pattern.

This dominance was very evident with my reading. Heidi had me sit and read a magazine while she watched me scan the print. She noted that my eyes do not work well together. I knew this very much so, as I always felt a difficult time converging on a very close object.

Funny, my eyes and tongue do the same thing at close objects
Funny, my eyes and tongue do the same thing at close objects

We would try various lenses while she asked me what it was like reading. The strangest thing happened once she put +0.50 in my right eye and +0.62 in my left eye.

I was retaining what I was reading.

That is the best way I can explain what I felt. I oftentimes had to read passages multiple times to comprehend, and thought nothing of it. I thought this was “normal,” and perhaps it was. But for the first time in my life, I had minimal eye strain while reading, and what I was taking in seemed to “stick” a little better.

That was the show for me. Sure, having better shoulder mobility is cool, but the fact that I can read more efficiently? Amazon will for sure stay in business now.

Aka my life, seriously.
Aka my life, seriously.

An Unreal Day 2

 So that ended my day treatment. I had upcoming 2 prescriptions for glasses, a splint, and some exercises to do.

But what exercises did Ron Hruska give? What will Zac’s splint look like? All will be answered in part 3.

Is it 90/90 hip lift? An adductor pullback? Early left stance?
Is it 90/90 hip lift? An adductor pullback? Early left stance?