Just when I thought I was out, the clinic pulls me back in.
Though I’m glad to be back. There’s just a different vibe, different pace, and ever-constant variety of challenges that being in the clinic simply provides. This has been especially true working in a rural area. You see a much wider variety, which challenges you to broaden your skillset.
Previously, I was all about getting people in and out of the door as quickly as possible; and with very few visits. I would cut them down to once a week or every other week damn-near immediately, and try to hit that three to five visit sweet spot.
This strategy no doubt worked, and people got better, but I had noticed I’d get repeat customers. Maybe it wasn’t the area that was initially hurting them, but they still were having trouble creep up. Or maybe it was the same pain, just taking much more activity to elicit the sensation.
It became clear that I was skipping steps to try and get my visit number low, when in reality I was doing a disservice to my patients. This was the equivalent of fast food PT—give them the protein, carbohydrates, and fats, forget about the vitamins and minerals.
Was getting someone out the door in 3 visits for me or for them? The younger, big ass ego me, wanted to known as the guy who got people better faster than everyone else. Yet the pursuit became detrimental to the patient’s best interest. There were so many other ways I could impact a patient’s overall health that I simply sacrificed in place of speed.
I only got them to survive without pushing them to thrive.
I see a lot of individuals proudly proclaim how many visits it takes for them to get someone out of pain, but pain relief is only part of the equation. There are so many more qualities we can address before we consider a rehab program a success.
This stark realization has reconceptualized how I structure a weekly rehab program. I now emphasize all qualities necessary to return to whatever task the patient desires, and attempt to inspire them beyond those initial goals.
You want to know what my visit average is right now?
I stopped counting, and started treating.
Let’s look designing the rehab week to take your clients to the next level.
To me, the most important aspect of patient care is knowing who you can and cannot treat. Stratifying your patients based on who needs to be referred out, and who you can help is essential to providing the best care.
Quite simply, there are few better resources out there that outline how to do this than Scott’s ebook.
In it, he delves into what relevant questions to ask, tests to perform, and establishing a relevant diagnosis. Often underlooked, yet exceptionally important components of the clinical examination.
Again, I cannot recommend Scott’s ebook and site enough. It’s a great resource for many things PT, including many of his eclectic and unique manual therapy techniques. Definitely check this guy out.
Rehabbing a 5th Metatarsal Fracture to High Level Basketball
In this podcast, I outline a case I worked on back when I was in the NBA D League.
This kid suffered a distal 5th metatarsal fracture with only a couple minutes to spare in a game. It was a brutal injury after one of the worst games in my life that I experienced, namely because we had three guys go down in one game.
Talk about awful.
I outline my entire process and every detail of what I did to get this kid back to high level basketball. A process that started with a fracture and ended with him establishing a franchise rebounding record the last game of the season. Pretty spectacular to say the least.
I feel very fortunate to have worked with such a driven and hardworking guy, and ultimately that was what his success hinged upon. Though minor, it was an honor to be this guy’s guide back to high level performance.
In this podcast, we dive into the following topics:
Did you miss Movement Debrief live yesterday? Though much more fun live, I have a video of what we discussed below.
This debrief was quite fun, as we had an impromptu viewer q&a. Thank you Alan Luzietti for the awesome questions! If you follow along live on Facebook or Youtube, I will do my best to answer any questions you ask.
Yesterday we discussed the following topics:
Why you should emphasize sagittal plane activities longer than you think
How to coach exercises to maximize client learning and compliance
Why detaching from your client encounters makes you a better clinician
Viewer Q&A – “centering from the chaos” & TFL Inhibition
Lastly, if you want the acute:chronic workload calculator I spoke about, click here.
As an official Ron Hruska groupie, the tour continued to the Big Apple to learn a little Postural Respiration.
And in NYC, everything is bigger.
The biggest city I had prior been exposed to was Chicago. The cities feel similar, only NYC has twice as many people on the same size streets.
I felt like this course was one of my less understood areas in the system, as Respiration was my first live PRI course. Taking this class the second time around really cleaned up a lot of things for me, and Ron was on point as always.
So let’s dive into the cranium…I mean pelvis….I mean thorax. Oh sorry, wrong course.
Laying the Foundation
The three foundational courses aim to inhibit tone, twist, torque, and tension in the human system by various methods.
In Postural Respiration, trunk rotation inhibits the system.
When these powers combine, the goal is to simultaneously maximize phases of gait and respiration. This development allows for total-body freedom to move, breathe, live, and create amidst our incessant desire to run on our built-in right stance autopilot.
There is nothing wrong with right stance, but it becomes wrong when it is all you know.
“There is nothing wrong with half the gait cycle until it becomes the full gait cycle.” ~Ron Hruska.
Make a Memory – The Zone of Apposition
Zone – An area that serves a particular purpose
Apposition – The condition of being side-to-side or close to one another.
With these definitions in mind, the zone of apposition (ZOA) is the cylindrical aspect of the diaphragm that lies next to the inner aspect of the lower mediastinal wall.
Since there are few proprioceptors in the diaphragm itself, the ZOA is largely influenced by ribcage orientation. The ZOA flattens if the ribs are elevated, anterior, and in external rotation; and domes in the converse. To maximize respiratory capacity, this space must be persevered at all costs via the rib’s governor—the abdominals.
“You can take my eye before my ZOA.” ~Ron Hruska
There are many ways that our respiratory system can be influenced. Here are some of the more important ones to think about:
Right diaphragm (respiratory) is large than the left (postural)
Right vagus nerve is longer than the left
Better lumbopelvic stability on right
Left thoracoabdominal rotation
Reach with right
Better Right ZOA to improve left chest expansion
Limited left hemidiaphragm respiratory function
Decreased right chest wall mobility
Increased accessory breathing muscle use
Eccentric-oriented rectus abdominis
Weak obliques and transversus abdominis
Wide infrasternal angles
Unilateral or bilateral rib flares
Being right-sided creatures
Poor sitting positions
The Result = the Pattern
Factor in the above influences with countless others, we begin to love right mid-stance, aka the left AIC pattern. The left AIC consists of:
The left innominate being anteriorly tipped and forwardly rotated.
The left lumbar spine being lordotic.
The spine being right oriented.
But what happens at the thorax?
The Brachial Chain
The right and left brachial chain (BC) consist consists of the following muscles:
When the left AIC pulls me into right stance, the right BC compensates to view the environment in the following manner:
The left ribs externally rotate; the right ribs internally rotate to center the body.
The thorax abducts to the right and begins rotating to the left (still right-oriented).
The left scapula is oriented in elevation and adduction; downward and external rotation; appearing retracted.
The right scapula is oriented in abduction and depression; upward and internally rotated; appearing protracted.
In the case of the superior T4 syndrome, the right scapula could appear retracted by the subclavius muscle compensatorily.
The Right BC may or may not be present in a Left AIC or PEC individual. There is also the possibility of someone being a bilateral BC, in which both scapulae protract on the ribcage and bilateral ribs flare. The Bilateral BC is like the PEC of the thorax.
Youz Best Assess
We can assess the BC with very common orthopedic tests, and due to the above positioning, we would expect the following results.
Decreased left horizontal abduction [<35] (if full, costoclavicular hypermobility or left anterior shoulder instability).
Decreased left shoulder flexion (if full, likely multidirectional instability).
Limited left cervical axial rotation
Limited right apical expansion
Bill Hartman does an excellent job below explaining what apical expansion is.
If one is a bilateral BC, then all motions should be limited on both sides, and if one is a superior T4 (explained later), you would expect limited left apical expansion.
Much like all the introductory courses, right BC treatment is fairly algorithmic. We follow a progression utilizing the BC opposition muscles, which include the triceps, lower traps, serratus anterior, and internal obliques/transversus abdominis. With these muscles, our goal is to create left thoracic abduction, left posterior mediastinal expansion, and right apical expansion.
ZOA nonmanual –> right lower trap and right tricep.
Here’s a ZOA nonmanual example:
And here’s a right lower trap / right tricep activity:
The right lower trap and right tricep activities work by retracting and posterior tilting the right scapula and rotating the left lower spine; promoting thoracic flexion.
The ultimate goal is to get to right lower trap and right tricep activities, but this progression assumes all your BC tests went negative. That rarely happens, so you may have to use some manual techniques:
ZOA nonmanual –> ZOA manual –> superior T4
Here’s an example from PRI of one of the manual techniques. There are several so I won’t show you all of them:
Suppose after you do the above and you get a positive left apical expansion test. That would indicate a superior T4 syndrome.
This syndrome is a compensatory pattern that occurs when respiratory demand increases. The right scalanes increase their tone, which externally rotates the upper four ribs on the right. This change would correspondingly result in left rib 1-4 internal rotation. The vertebrae in this region also begin rotating right. This rib positioning would explain why apical expansion would be limited on the left.
I ‘splained it here in the video below:
When we run into this pattern, we have to use a few other tricks up our sleeve:
Subclavius manual technique –> left lower trap and left serratus exercise
The left lower trap and left serratus exercise helps by rotating the mid-thoracic spine to the right, internally rotating the ribs. A desired kyphosis would also be created
Here’s a video of some young man doing this classic activity
One of the biggest pieces that I picked up from this class regarded patient education. With all the PRI nonmanual and manual activities, our goal is to give the patient a frame of reference. Finding and feeling these movements, muscles, and positions is what helps drive the patient into alternating and reciprocal activity.
We use nonmanual techniques to promote motor learning with these references, and manual techniques are merely a way to guide the patient to these references.
So if anything, the course itself taught me to reinforce why feeling this activity in this area is important to the patient’s experience. How is this technique is going to help them, why do I have to put my hands on your ribcage. The more we inform the patient the better.
So there you have it. Another great PRI course, and my understanding is a little less hazy. I look forward to the next one. If you haven’t made it to a PRI course yet, please do so. You can thank me later.
Wait, you didn’t think I’d forget some good quotes right???? 🙂
(In)famous Ron Quotes:
“The appendages tell you what sense you are in. Sympathetic. Parasympathetic.”
“This is not an anatomical and biomechanics course.”
“Asymmetry is a gift. Why would you destroy it?”
“Every muscle you have has a purpose.”
“If you don’t inhibit something you are dead.”
“There is no such thing as a shoulder. You have two of them.”
“There is no such thing as a body. I see two.”
“I love fascia, but fascia is not restricting you. Tone is restricting you.”
“The diaphragm is the only muscle in your body. It’s the first and last one you will use.”
“You’re treating four patients in an hour? I’m going to pretend I didn’t hear that.”
It seems like I took this course forever ago, but reviewing this post reminded me why I love the NOI group so much. I feel as though their message is one you cannot get enough of.
As for GMI itself, I find that it is great for people who most every movement hurts, as well as an educational piece. From a PRI perspective, it is also useful. I have had patients imagine contracting their glute max and go neutral. Crazy stuff.
Such a great class. Here we see updates to the science behind “The Sensitive Nervous System”, as well as some neat tweaks to our neurodynamic testing. My favorite pieces were on the immune system and genetics.
I officially eclipsed my longest work day ever. Started seeing patients at 7:30 am and finished training my last client at 10 pm.
So exhausting, but the bright side is my new schedule prevents me from waking up that early ever again! Hooray for sleeping in…sort of.
I figured while I had some time in the airport before my next course, I would write a little something about a patient I evaluated right before my lunch break on this long day. Needless to say, I didn’t get much of a break.
This lovely lady is a nurse with a history of chronic left hip pain. She has predominately been treated surgically via labral repairs and muscle reattachment. Her most recent symptom exacerbation involved putting on her socks about a month prior. She heard a pop as she bent over and could not walk.
She initially saw two ortho docs. One specializes in total hips, the other in scopes. Since she was not appropriate for a total hip, this doc referred this lady to his associate.
After some imaging was done, she found out that she could not have surgery because she had several muscle tears. Or in the language that the doctor used:
“I have nothing to work with. Your hip is shredded up like cheese.”
This lady knew no other treatment but surgery, and hearing this news was devastating for her. Thoughts of a brutish life and an end to her fulfilling job flooded her mind. This doc referred to PT while conveying to the patient that this avenue was a mere dumping ground.
She walks back into the evaluation room, limping with the cane in excruciating pain.
Healthcare practitioners are the hardest people to treat. Knowledge is power, but the extensive biomechanical knowledge she had was detrimental in this case.
The subjective basically consisted of her telling me all the biomechanical issues she had. This pain is the bursa; running around the gluteus medius and minimus, down the illiotibial tract, blah blah blah puke.
But I listened intently to her story and how this recent episode devastated her life.
I finally asked her what her goal was for therapy? She replied…
“When you have a hip like this, what goal can you have?”
There were so many strikes against me for this lady. If you factor in what her history, what doctors said, her thoughts on her complaint, her belief that therapy could do nothing, her lack of goals, and her pain severity; let’s just say I was quite overwhelmed.
After I composed my thoughts, I knew what needed to be done.
I performed an abbreviated objective exam to determine movement sensitivity and autonomic nervous system status via PRI testing. Based on my tests and measures, she was classified from a PRI perspective as a normal human being from the planet where?
I told her this finding, and proceeded to go into explaining how pain works. You never know how someone so indoctrinated into a biomechanical model is going to react to this thought process, but it was the only shot I had.
I used the analogy of pain as a sophisticated home security system. One so sophisticated that it can differentiate when calling 911 is appropriate; 911 being pain. Her hip trouble history was similar to being robbed in the past, so her home security system called 911.
If you have been robbed once, you will likely take extra precautions not to get robbed again.
Therefore, when she does something nonthreatening like put socks on and gets excruciating pain, it is not necessarily because she got robbed. It is as if her main console (i.e. her brain) calls 911 just because someone suspicious is walking near the street to her home. This episode was the result of her security center calling the cops at an inappropriate time.
Surprisingly, she totally understood this explanation, and gave me the following response:
“I never had anyone explain it to me that way.”
I sealed the deal by using her current hopelessness to my advantage. I mentioned that she felt this was the only option she had left. I felt I could help her as long as she put in the work.
She was sold.
The treatment we worked on was simply working on her breathing in hooklying. I helped her guide her ribs down to get as much exhalation as possible. We worked on this for about 10 minutes until she got the concept.
I reassessed all her hip motions…No pain. She got up and walked…No pain. She looked at me and asked:
“What the hell just happened?”
I told her we got her home security system reset via the autonomic nervous system.
She walks back into the evaluation room, limping with the cane in excruciating pain. She leaves the evaluation room smiling and holding the cane.
I don’t know what pisses me off more with this case, the words her doctor used, or the fact that this lady had never heard how pain works.
She was a healthcare practitioner who had no idea that pain worked in this way, and that scares me.
We see two very influential professions who think purely from a biomechanical model, and likely explain complaints to people in this fashion. Think of the number of people these clinicians will see, perpetuating biomechanical faults as the sole cause of one’s pain. We can see now why our jobs are challenging.
Pain neurobiology is becoming more prominent in the PT realm, but we are only small fish in a very big pond. And due to our status, we will have a hard road ahead converting medicine to this model. I was lucky in this case, but I cannot tell you how many times I lose a patient when I go this route.
A few get it, some superficially get it, and many will not buy it.
But I see a paradigm shifting over the horizon. A light at the end of the tunnel. I got another healthcare provider to realize current pain theories, and she is eager to learn more. I feel we need to focus more of our efforts here.
We need to stop arguing with each other over which treatments do and do not work and the rationale why. We are all attacking the same thing under the same framework. We are all reducing the perception of pain as a threat. And that is all pain is. A perception.
We need to shift our focus to educating those professionals not initiated on how this science works. We need doctors, nurses, therapists, front office staff, and everyone else involved in health care all on the same page. And until we do so, we will be stagnant in our current state.
The arguments we make regarding treatment will not matter until we educate the masses on the underlying framework for their pain experience.
This is a chapter 14 summary of the book “Movement” by Gray Cook.
Corrective exercise is focused on providing input to the nervous system. We are allowing the patients and clients to experience the actual predicament that lies beneath the surface of their movement pattern problem. It is okay for mistakes to be made, for these errors help accelerate motor learning. Minimal cueing should be utilized, as we want to patient to let them feel the enriching sensory experience.
Motor Program Retraining
There are several different methods in which we can achieve a desired motor output.
1) Reverse patterning – Performing a movement from the opposite direction.
2) Reactive neuromuscular training – Exaggerating mistakes so the patient/client overcorrects. Use oscillations first, followed by steady resistance.
3) Conscious Loading – Using load to hit the reset button for sequence and timing.
4) Resisted exercise – Makes patterns more stable and durable.
When you can deadlift that much, most anything is stable and durable.
This is a chapter 13 summary of the book “Movement” by Gray Cook.
Back to the Basics
Mobility deficits ought to be the first impairment corrected. Optimizing mobility creates potential for new sensory input and motor adaptation, but does not guarantee quality movement. This is where stability training comes in. In order for the brain to create stability in a region, the following ought to be present:
Structural stability: Pain-free structures without significant damage, deficiency, or deformity.
Sensory integrity: Uncompromised reception/integration of sensory input.
Motor integrity: Uncompromised activation/reinforcement of motor output.
Freedom of movement: Perform in functional range and achieve end-range.
There are 3 ways to gain mobility:
1) Passively: Self-static stretching with good breathing; manual passive mobilization.
2) Actively: Dynamic stretching, PNF.
3) Assistive: Helping with quality or quantity, aquatics, resistance.
In order to own our new mobility, we use various stability progressions to cement the new patterns. There are three tiers in which stability is trained:
1) Fundamental stability – Basic motor control, often in early postures such as supine, prone, or rolling.
2) Static stability – done when rolling is okay but stability is compromised in more advanced postures.
3) Dynamic stability – Advanced movement.
We progress in these stability frames from easy to further difficult challenges.
Assisted → active → reactive-facilitation/perturbations
Since stability is a subconscious process, we utilize postures that can challenge this ability while achieving desired motor behavior. We can also group the various postural progressions into 3 categories:
1) Fundamental – Supine, prone, rolling (requires unrestricted mobility).
2) Transitional – Postures between supine and standing such as prone on elbows, quadruped, sitting, kneeling, half-kneeling.
3) Functional: Standing variations to include symmetrical and asymmetrical stance, single leg stance.