How to Treat Pain with Sitting – A Case Study

Case studies are much more valuable than many give credit for.

It is this type of study that can often lead to sweeping changes in how further research is conducted, often create paradigm shifts in their own right.

After all, there was only one Patient H.M.

One thing that I wish I saw more in case studies was the clinician’s thought process. Why did they elect to do this treatment over that, what were they thinking when they saw this? How do they tick?

I was fortunate enough to have an online client of mine suggest to that I make her a case study, and it was a very rewarding experience on both fronts.

My hope is that you can see how a clinician thinks first-hand, and see the challenges a clinician faces…

When you can’t work with your hands.

Continue reading “How to Treat Pain with Sitting – A Case Study”

Course Notes: PRI Cervical Revolution

Where are all the People?

I recently made the trek to Vermont for the first rendition of PRI’s Cervical Revolution course; a course in which the attendees doubled the population of the entire state.

We were on our 1776 shit.
And we were on our 1776 shit.

It was nice to go to the class with a bunch of old friends. You always learn better that way, and I couldn’t have been more excited to get the band back together.

The puns are endless for this course title.
Reason #62 why not to be facebook friends with me

And even more so, I got to meet a lot of good folks for the first time. It was a real treat.

Viva la Mullin Revolucion!
Viva la Mullin Revolucion! The puns are seriously endless.

This course was meant to update the former craniocervical mandibular restoration course (which I reviewed here and here), with extra emphasis on the cervical spine and OA joint.

In this blog however, I will not touch much on the cervical spine positioning. I still have several questions regarding the mechanics. Some spots within the manual seemed to be conflicting; the blessing and curse of a first run-through. I will update this piece once I get these points figured out.

That said, the revolution helped fine tune the dental integration process for me. I have been working a bit with a dentist, and I have a bit more insight in terms of what devices they are using for whom.

Let’s go through my big a-ha moments.

This post will not be gone in a day or two.
This post will not be gone in a day or two.

Smudging 901

The human body is symmetrically asymmetrical. When we have capacity to alternate and reciprocate, we are able to separate the body into parts to form a whole.

If you lack integration, then there are no parts. You have an it. This is how somatosensory smudging works. Lacking parts creates a pattern. A pattern could create a threat to the system, or a threat to the system could create a pattern.

We need to be able to differentiate our parts.

Neck Problems Do Not Exist

The craniocervical region is incredibly mobile for a reason. That reason is to create precision for our sensors: vision, audition, olfaction, respiration, and vestibular sensation. This precision occurs reflexively, whereas other appendages act proprioceptively.

These sensors drive the neck. Losing the ability to sense is what can increase the need for a neck to become stable. And when you can’t move a stable neck, teeth may be one thing you try to use.

That's why I never neck with my teeth #doubleentendre
That’s why I never neck with my teeth #doubleentendre

In this course, the sensors we focus on are our canines and molars. Canines are transverse-plane antennae; necessary for lateral guidance. Molars, on the other hand, let us know what side we are on (frontal shifting).

Two TMCC Possibilities

Ron spent a much greater amount of time discussing two patterns that were briefly mentioned in previous courses: the left sidebend and right torsion.
These two patterns are possibilities that can occur at the cranium in a right TMCC pattern; and it all depends on what happens at the sphenoid.

If I find this girl I will marry her.
If I find this girl I will marry her.

The Left Sidebend

The left sidebend pattern is typically what we think of with the RTMCC. The atlas is rotated to the right, the occiput rotated to the left, the sphenoid oriented to the right, and the mandible oriented to the left. This positioning cants the mouth left and upward; creating a counterclockwise facial rotation.

It looks like this:

Taken from an article by James and Strokon. Check out the original piece: http://www.researchgate.net/publication/6906058_Cranial_strains_and_malocclusion_V._side-bend--part_I
Taken from an article by James and Strokon. Check out the original piece:
http://www.researchgate.net/publication/6906058_Cranial_strains_and_malocclusion_V._side-bend–part_I

Test-wise, these individuals are limited in cervical sidebending to the right and axial rotation to the left.

Treatment will consist of developing left sided awareness, especially of occlusion. We want left abs to coactivate with a right SCM to establish neutrality. Here is the base repositioner to do that:

Right Torsion 

Here is where things get a little crazy. In these individuals the atlas, sphenoid, and mandible are right oriented; with variable positions occurring at the remaining cranial bones. This creates a right mouth cant and a subsequent clockwise facial rotation. This cant begets an over-referenced right sided occlusion which can become difficult to move out of.

It looks like this:

This is also from a James and Strokon article. Check it out here: http://www.ncbi.nlm.nih.gov/pubmed/16617884
This is also from a James and Strokon article. Seriously, these articles are gold. Check it out here:
http://www.ncbi.nlm.nih.gov/pubmed/16617884

Test-wise these individuals will have bilateral limitations in lateral flexion, yet left axial rotation alone shall be limited.

These individuals will likely need some dental integration due to the over-right lateralized cranial positioning; many of these folks have had craniocervical trauma.

Therapy treatment will involve alternating activity, and here is our repositioner for that:

Splints on Splints 

One of the big reasons I took this course again (aside from having a con ed problem) is because I wanted to really iron out who ought to get what splints. I definitely learned a much better appreciation for each splint type PRI recommends, and it was nice to see what new stuff they are using. Here are the big ones.

The PRI MOOO

Close, though the anterior portion of the splint is built up a bit.
Close, though the anterior portion of the splint is built up a bit in the actual MOOO.

This splint is the new one PRI is making, which is similar to your typical flat plane splint. The big difference is the anterior portion of the splint is built up to allow for better canine reference. Canines are what allow an individual to twist and turn, so the better we can feel these guys the better triplanar capabilities we will have

Who gets it: RTMCC folks; those who have a hard time finding teeth, more neurologically unstable folks.

The Gelb Splint

My muse.
My muse.

This guy is the one I was given. This splint helps bring the mandible slightly forward, creating better craniocervical mobility. There is also a lingual bar to reduce tone on folks with active tongues.

Who gets it: Individuals with narrow bites, active tongues, people who talk a lot throughout the day, one who can protrude the jaw forward, disc issues. Generally people who are fairly stable will get these, as they allow for much more movement freedom compared to the MOOO. Makes sense now why I was given this as I had no patho-compensatory patterns.

The EMA

ema

This device helps retrude the cranium to improve an airway and is usually worn only at night.

Who gets it: Right torsion patients, those with discal compression, individuals with sleep apnea, prophylactically.

ALF Orthotics

The one and only
The one and only

These are the expensive beasts. It is an appliance that is worn around the maxillary and mandibular teeth to promote maxilla expansion and cranial flexion. You will likely need orthodontics after this one, as the teeth have a tendency to move.

Who gets it: Individuals with high palates (bilateral or unilateral), individuals who are very neurologically unstable, excessive disc popping.

C’est Fini

So there it is. While it had the first-run bumps, this course’s information is priceless; necessary to truly integrate PRI to it’s fullest potential. Attend, find yourself a dentist, and help some people.

Infamous Ron Quotes

  • “There is a lot of feet in your mouth.”
  • “Foramen magnum is life.”
  • “Upper trap is a thermostat.”
  • “I want to twist the hell out of you so you can untwist and enjoy life.”
  • “You will never develop abdominal obliques without lateral pterygoids.”
  • “Dysautonomia is a bad ebola.”
  • “I’m no different than your protoplasm.”
  • “If you like feet you gotta like neck.”
  • “That’s called vagal sciatica.”
  • “Is it okay if I produce and Arnold Chiari syndrome on you?”
  • “The best physical therapists are ones who integrate with other disciplines.”
  • “The best sensory organ you have is your teeth.”
  • “Cervical revolution is a gift.”
  • “If you don’t like your spouse give them a NTI.”
  • “A hyoid that’s high is a cranium that’s forward.”
  • “You stretching out a neck is not going to get a cranium to go back.”
  • “The worst thing you can say to a patient is don’t do it.”
  • “There is no effectiveness in treating a symptom.”
  • “If you have lateral occlusion you poop better.”
I'm sure it's slightly different...
I’m sure it’s slightly different…

Treatment at the Hruska Clinic – Initial Evaluation

For part 2, click here.

For part 3, click here.

“Do you produce enough saliva?”

That was the first interview question Ron Hruska asked me; something I will never forget.

No worries, I do.
No worries, I do.

I went to Lincoln, NE for almost a week to take a course, get treated, and observe PRI in it’s purest form.

I wanted to see Ron out of curiosity and because I cannot achieve neutrality on my own. I have done most every exercise that could be thought of and been “worked on” by my fellow comrades and a couple PRI instructors in courses; nothing could budge.

I knew I needed some type of orthotic to get somewhere; the question was which one?

Subjective Complaints

I do not have any pain really. My only complaints are a tight neck and I can’t seem to deadlift without feeling most of the effort in my back.

I don’t see this deadlifting problem as a form issue necessarily. Interning with Bill Hartman at IFAST cleaned that up, and for a long time I could feel glutes and hamstrings all day when I deadlift.

After each great pull, this occurred.
After each great pull, this occurred.

But not now.

Other “issues” I have

  • Left TMJ clicks; nonpainful.
  • Clench jaw at night.
  • Eye strain after reading on a computer too long (duh).

By PRI standards, I am a classic PEC. I have no pathology anywhere, but I am limited in almost every motion.  I knew this and so did Ron.

Objective Exam

 First Ron had me walk and was pointing out some things to my student-to-be Trevor, and then got me up on the table to check my hips.

“Here’s your problem.”

My hip external rotation was about 70 degrees on the left, 40 on the right.  He then checked my hip abduction, which was a solid 30 degrees bilaterally.  The next test followed in a logical progression…

He gloved up and checked my bite.

Sort of what's going on with my cranium.
Sort of what’s going on with my cranium.

He noted I had a type I occlusion bilaterally and noticed my chipped front tooth. He wanted to show me which tooth was grinding on that, so he asked me to move my jaw forward.

I couldn’t do it.

He gave me a mirror to help see what I was trying to do.

I couldn’t do it.

He put a towel over my eyes and dimmed the room.

I easily contact my front teeth, gain 30 degrees of hip abduction on both sides, had equal hip external rotation, and for the first time ever had a negative thomas test.

We figured out what I needed.

For realzzz
For realzzz

The Needed Orthotics

Ron concluded that I was a tongue thruster, had a very narrow/crowded mouth, and my visual system was patterned enough to drive my nervous system into extension. He also explained, which blew my mind, that a reason I always put my hands in my pockets is to provide a reference center for my very active hip flexors.

My right hand is my TFL, my left hand is my psoas.

And here I thought my other one was giving a high five.
And here I thought my other one was giving a high five.

The next process was to contact his dentist to fit me for a Gelb splint and set me up with a day at PRI vision.

Before chatting with the dentist, he checked my mouth one more time just to make sure he had all the information he wanted to say. It was this second look that Ron noticed that I still have my wisdom teeth.

“How far do you want to get into this?”

Stay tuned for day 2.

 

Stupid bunions! Oh sorry wrong course.
Stupid bunions! Oh sorry wrong course.

For part 2, click here