Impingement, Trusting Your Assessment, Noncompliance, and the Off-Switch – Movement Debrief Episode 15

If you are beyond sad that you missed last night’s Movement Debrief, number 15, I got your back. This time both audio and video are available #growing up.

Here’s what we talked about:

  • What impingement is
  • How to treat impingement at any joint
  • When do local inputs matter?
  • Trusting your assessment process
  • When to go beyond your assessment process
  • Why context matters
  • Making the most of noncompliant people
  • Dealing with bad situations
  • The importance of having an “off switch”

If you want to watch these live, add me on Facebook, Instagram, or Youtube. They air every Wednesday at 8:30pm CST.

Enjoy.

 

Here were some of the links I mentioned in this Debrief.

The 3 Biggest Basketball Conditioning Mistakes

Practical Basketball Conditioning

How to Treat Pain with Sitting – A Case Study

Neurocoffee

 

Movement Debrief Episode 1: Meet the Patient at Their Story

A Live Movement Video Series

Hey party people.

I recently started doing some live feeds on the interwebz. You can check me out on Facebook and Youtube if you want to see me live.

Otherwise, I thought I’d share with the very first episode of “Movement Debrief.”

Here we dive into the following topics:

  1. The importance of reflection
  2. Using similar language to the patient.
  3. De-threatening that language
  4. Restoring sagittal plane control
  5. A case for manual therapy

Enjoy!

The Ultimate Guide to Treating Ankle Sprains

A Humdinger No Doubt

 

Ankle sprains. Such a bugger to deal with.

Worse than childbirth, as David Butler might say.

 

Ankle sprains are one of the most common injuries seen in basketball. The cutting, jumping, contact, fatigue, and poor footwear certainly don’t help matters.

Damn near almost every game someone tweaks an ankle.

Treating ankle sprains in-game provides quite a different perspective. Rarely in the clinic do we work with someone immediately post-injury. Instead, we deal with the cumulative effects of delayed treatment: acquired impairments, altered movement strategies, and reduced fitness.

The pressure is lower and the pace is slower.

You shed that mindset with the game on the line. You must do all in your power to get that player back on the court tonight, expediting the return process to the nth degree.

I had a problem.

Figuring out the most efficient way to treat an ankle sprain was needed to help our team succeed. I searched the literature, therapeutic outskirts, and tinkered in order to devise an effective protocol.

The result? We had 12 ankle sprains this past season. After performing the protocol, eight were able to return and finish out the game. Out of the remaining four, three returned to full play in two days. The last guy? He was released two days after his last game.

It’s a tough business.

The best part was we had no re-sprains. An impressive feat considering the 80% recurrence rate¹.    Caveats aside, treating acute injuries with an aggressive mindset can be immensely effective.

Here’s how. Continue reading “The Ultimate Guide to Treating Ankle Sprains”

Change The Context: 3 Tools to Treat Neck Pain

Basket Case Study

The other day I woke up with some right-sided neck pain. I had some discomfort and slight limitations rotating or sidebending right.

Now I’ve already completed many systemic-oriented treatments, and don’t really have a go-to non-manual for the occasional crick in the neck. I was unable to get any manual therapy, nor were self-mobilizations effective.

What’s a guy to do? Continue reading “Change The Context: 3 Tools to Treat Neck Pain”

Manual Therapy Musings

When I think About You…

Prompted by some mentee questions and blog comments, I wondered where manual therapy fits in the rehab process.

To satisfy my curiosity, I calculated how much time I spend performing manual interventions. Looking at last month’s patient numbers to acquire data, I found these numbers based on billing one patient every 45 minutes (subtracting out evals and reassessments):

  • Nonmanual (including exercise and education) = 80%
  • Manual = 20%
  • Modalities = 0%!!!!!!!!!!!!
Especially happy with the last number...and that I forgot how to work these useless things.
Especially happy with the last number…and that I forgot how to work these useless things.

Delving a bit further, here’s my time spent using PRI manual techniques versus my other manual therapy skill-set:

  • PRI manual = 14%
  • Other manual = 6%

As you can see, I use manual therapy a ridiculously low amount; skills that I used to employ liberally with decent success.

Skills-that-I-learned-in-the-mountains
Greatest skits on the internet per Cochrane review.

 

There’s a reason for the shift

I want my patients to independently improve at all cost and as quickly as possible. The learning process is the critical piece needed to create necessary neuroplastic change; and consequently a successful rehab program.

Rarely is learning involved in manual therapy. Continue reading “Manual Therapy Musings”

9 weeks with Bane, I mean Zac…Oops Sorry Wrong CI

Only one wears glasses but both are alternating and reciprocal warriors.
Only one wears glasses but both are alternating and reciprocal warriors.

Note from Zac: This is my first guest post, and to start things up is the one and only Trevor Rappa. Trevor was my intern for the past 9 weeks and he absolutely killed it. Here is his story.

It’s very exciting for me to get to write a guest post for Zac’s blog that I have read so many times and learned so much from. The experience I have had with him over these past 9 weeks has been incredible and I hope to share some of it with all of you that read this.

He challenged me to think critically in every aspect of patient interaction: how I first greet them, which side of them I sit on, the words I use, and how I explain to the patient why I chose the exercises they’ll go home with. All of this was to create a non-threatening environment to help to patient achieve the best results they can.

He also taught me how to educate patients with a TNE approach, incorporate other interventions such as mirror therapy into a PRI based treatment model, and deepened my understanding of the neurologic concepts behind performance.

Therapeutic Neuroscience Education

Perception of threat can lead to a painful experience which will cause a change in behavior. It’s the PT’s role to introduce a salient stimulus to attenuate the perception of threat in order to cause a positive change in experience and behavior (Zac and I came up with that, I really like it).

Pain is not the enemy. Teaching patients that their pain is normal and it doesn’t always mean that they are damaging themselves can be challenging as pain is often the reason patients seek out or are referred to PT. Some of the points we tried to teach patients were

  • Pain is there to keep you safe, which is good
  • Pain does not equal tissue injury
  • No pain, no gain is not what we’re looking for
  • Discomfort is okay
  • Knock on the door of pain, don’t try to kick it down

A large part of educating patients is helping them re-conceptualize why they are having pain. Most patients think of pain in terms of a pathoanatomical model (ie tissue abnormality=pain) and this is perpetuated by a lot of members in the medical community. The pathoanatomical language often causes a higher perception of threat and induces greater feelings of being broken, hopeless, and unfixable.

Re-educating the patients that what they are experiencing is normal and teaching them why it is normal helps decrease their perception of threat. We do not want to use language that will make patients more threatened, like telling a 20 year old that they have the spine of an 80 year old (numerous times our patients have been told that by other medical professionals). Getting them out of a mindset that if they move a “faulty tissue” they will make their situation worse is one step in this process.

Regardless of whether the patient is dealing with a more acute injury or one that has become chronic, there are three things we taught each patient that we would do in PT to help decrease some of the sensitivity they may be dealing with. Those three things are movement, space, and blood flow. These three things require the patient to be active in their therapy which gives them control.

Many of the patients with chronic conditions had stopped doing the things they enjoyed. Giving them activities which they can do without perceiving pain, or that can help decrease their pain, shows patients that they do not need to rely on external passive interventions to feel better. Getting patients to believe/understand that they have the control and power to make themselves feel better is one of the most important things a PT can do.

Mirror therapy, sensory discrimination, and PRI

Learning how to use different interventions to help decrease sensitivity and pain was huge for me. We used mirror therapy with different types of patients whether they had chronic pain or were post-surgical. The mirror activities usually started with the patient moving their unaffected limb while watching their affected limb move in the mirror. For example, if you right arm hurts you’d move your left arm while looking at the mirror because it would appear that your right arm is moving. We would progress patients to where they were moving their affected limb behind the mirror while still watching the reflection of their unaffected limb moving in front of the mirror. With the example above, you would still be watching the reflection of your left arm in the mirror making it look like your right arm is moving but would also be moving your right arm behind the mirror. This helped introduce patients to moving a sensitive area without experiencing pain, thus decreasing the threat of movement.

Numerous RCTs have shown this to be true.
Numerous RCTs have shown this to be true.

Another intervention I had not used before was sensory discrimination. We used this mostly in our post-surgical or more acute population to help decrease the local sensitivity after an injury and to try de-smudgify (that may or may not be an actual word) their homunculus [note from Zac: Totally is].

Sharp-dull discrimination was used first, then we progressed to two-point discrimination and usually ended with graphesthesia. The progress for patients from not being able to discriminate between sharp-dull to having graphesthesia showed me how powerful the role of the somatosensory homunculus is in the pain experience.

And of course, I learned more PRI from Zac. He challenged me to use more integrated non-manual techniques with patients while also limiting the number of cues I used. This was great because it is very easy for me to over coach these techniques. He also gave me a better understanding of some of the big concepts in PRI, such as neutrality.

Neutrality vs Hypofrontality

Neutral is a huge word in PRI that is often thought of as the end game when in reality it is just the beginning of a PRI treatment. The end goal is to get someone alternating and reciprocal. The idea of neutral always made sense to me as a good goal for performance as “neutral” joint positions is where the greatest force would be able to be produced. Talking to Zac about this he brought up what Bill Hartman Grandpa 🙂 has said: Neutral is a neurologically prefrontal state in which learning can occur, as the prefrontal cortex (PFC) is active during tasks that require attention. However, this is not a state you want an athlete performing in.

An active PFC is good when athletes or patients are in rehab because their cerebellum and basal ganglia are learning new movements that can then be used with less activity from higher cortical areas during performance. The movements used during these activities can become reactive after enough learning, practice, and repetition (those 3 things go hand in hand).

During performance or training we would not want an athlete using the higher cortical areas that elicit attention as this would make them slow and inefficient. Instead, we would want them fast and efficient (ie reactive and reflexive). A transient state of hypofrontality allows an athlete to reach a state of “flow”, which Mihaly Csikszentmihalyi describes in his book Flow, which is where the highest levels of performance occurs. This would allow the lower reactive (cerebellum and basal ganglia) and reflexive (brain stem) centers of the brain to essentially take over making them fast and efficient.

So from a theoretical neurologic stand point you do not want an athlete in a prefrontal state during performance. Good rehab and programming can help them become alternating and reciprocal through graded exposure and relearning of certain movement patterns in a neutral (prefrontal) neurologic state. Once this foundation is there, power and capacity can be added through training (which Zac talks more about here ). This may allow an athlete to stay alternating and reciprocal during transient states of hypofrontality when performing, not “neutral”.

Another concept that stood out to me from talking with Zac is the difference between extensor tone and extension. Extensor tone is necessary for power production during performance but it does not necessarily mean that the athlete is going into a position of extension. When someone is in extension they limit their degrees of freedom for movement and thus their movement variability. Using extensor tone from a neutral position, for lack of a better term, would allow them to display power while maintaining their potential movement variability (be alternating and reciprocal). This idea was something that made things click for me.

In summary…

I learned a lot from Zac and want to thank him for all his help and time he spent teaching me. Needless to say, this was an amazing clinical internship for me and I cannot recommend enough that other students should try to get Zac as their CI or for patients to get treated by Zac. He is the real.

Zac Cupples and Iron Sheik same thing
Zac Cupples and Iron Sheik same thing

And now what everyone has been waiting for… Zac quotes

Help for cueing exercises

  • “Shakin’ like a polaroid picture”
  • “We don’t want Fat Joe and the lean back”
  • “Do you remember the three little pigs? I want you to be the big bad wolf and blow their house down”
  • “Do you have the big 3? Jordan (L abs), Pippen (L adductor), and Rodman (L glute med)?”
  • “We like a tight right butt and we cannot lie, the other therapists can’t deny”
  • “I’ll start calling him Buffalo Bill, cause he’s abducting like crazy”
  • “We don’t want you to have hamstrings like Goldmember”
Hamstrings like Goldmember = POTS
Hamstrings like Goldmember = POTS

Zac after getting his wisdom teeth out, he doesn’t remember saying these things

  • “I have lateral trusion!”
  • “Check out this IR” and then he self-tested his own HG IR
  • “I ain’t got time to bleed”
  • “Nobody makes me bleed my own blood”

Other favorites

  • “If you ain’t assesin’ you guessin’”
  • “There’s 45 miles of nerves in the human body if you put them all in a straight line, but don’t try it at home cause you’ll die.”
  • “…hmm..interesting” in Bill Hartman Grandpa’s voice
  • “…sure about that?” in grandpa’s voice
  • “Her teeth told me she had bunions”
  • “I don’t know why he told us the same diagnosis five times.”
  • “Breathing is really important. The research has shown if you don’t do it you will die”
  • “How about this word, variability. How about this word, salience. How about this word, anti-fragile. How about this word, POTS.”

Trevor Rappa is a student at Columbia University and will graduate this May with his DPT. He has clinical experience with Lori Thomsen at the Hruska Clinic and with Zac Cupples at East Valley Spine and Sports. Upon graduation, he will be working at Peak Performance in NYC. You can get in touch with Trevor by email at trevor.rappa@gmail.com or on twitter @TrevorRappa.

 

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

Course Notes: PRI Impingement and Instability – Cantrell Edition

A Quick Trip Home

 I made my first trip back to my roots since moving out west to watch Mike Cantrell’s version of one of my favorite courses: Impingement and Instability.

Will be said every time I go back to Illinois
Will be said every time I go back to Illinois

Yes, if you are wondering, my family does hate me for not being able to visit them.

Mike absolutely killed all of the various topics we covered, and his ability to coach some of the advanced PRI activities is second to none. I had a blast learning from him.

I won’t go over all the nitty gritty like I did here, but here were some of my favorite concepts that we covered.

Learn on.

The I&I Conundrum

 Impingement occurs due to the human system’s conflicting demands.

We face a battle between instability and stability. Flexion allows for movement variability, which is desirable in the human system. Variable movement reduces threat perception.

However, system flexion leads to increased instability and the risk of falling forward. To combat this risk, impingement may occur by compensatory extension. Extension begets joint and system stability, yet system variability is minimized. Increased stability is desirable when under threat, but not for long term.

The “goal” then, would be to build control within flexed instability so the system can stay variable; to remain upright without extension. As Charlie Weingroff would say, we want “control within the presence of change.” That is alternating and reciprocal movement.

Do you think it would bother Charlie if I quote him in a PRI blog???
Do you think it would bother Charlie if I quote him in a PRI blog???

That doesn’t mean you have to do silly little PRI exercises for the rest of your life. PRI activities are simply neuromuscular training tools that help differentiate left vs. right to create system variability. Graded motor imagery’s laterality training does the same thing, albeit at the most rudimentary level. PRI is a progression from that.

Once we develop triplanar awareness, all we need to do to maintain system variability is continually reinforce variable position throughout the day.

 Reference is the Key

The way we can remain upright without impinging into extension is to develop interoceptive and exteroceptive awareness of stability points in system flexion. More specifically, stability points created in left stance.

The name of the game is reference centers, which keep a flexed system upright in the environment. These centers allow one to engage the opposition muscles necessary to achieve left stance. In neutrality, reference centers give us control in the presence of change.

If we lose a frame of reference in flexion, then we lose stability. If we lose stability, we extend to become stable. If we extend to become stable, we impinge to create reference.

Stability leads to extension, extension leads to impingement, impingement, leads to suffering.
Stability leads to extension, extension leads to impingement, impingement, leads to suffering.

I&I mentions six official reference centers that send us into the RAIC/LBC pattern. However, there a several different ways we can create a reference. I’ll list the sweet 6 as well as a few others that were mentioned:

  • Right medial longitudinal arch when in left AF IR – Gives us right glute max
  • Left posterior (center) calcaneal tuberosity – Gives us left IC adductor
  • Left Ischial tuberosity – gives us left hamstring
  • Left anterior acetabular femoral capsule/right posterior hip – Gives us left stance
  • Left IO/TA/left posterior ribcage – gives us exhalation and a ZOA
  • Right lateral posterior upper ribs and right scapular when in left AF IR – gives us inhalation within a state of flexion.
  • Right lateral knee – Gives us right glute max
  • Tongue on the roof us the mouth – Pressurizes maxillary arch (aka mouth diaphragm) and relaxes neck musculature.
  • Left molars – Equivalent of left calcaneus.
  • Right pisiform – Your hand’s calcaneus. Feel this in the closed chain to get a right serratus.
  • Left index finger – to create an arch in the left hand; allows for grasping objects.

Compensatory Strategies

 If one cannot find these references, one will right lateralize. The left AIC/right BC pattern is the norm. We are biased to be right dominant, and it is a way for us to maintain some semblance of stability.

There are several ways that individuals attempt to compensate for this bias. Some do nothing, some develop the capacity to alternate and reciprocate, some become left handed, some increase extensor tone to PEC levels.

Newest PRI orthotic for my favorite compensatory strategy. Unfortunately only 10% of you will understand...
Newest PRI orthotic for my favorite compensatory strategy. Unfortunately only 10% of you will understand…

In most cases, becoming alternating and reciprocal is desirable.

 I Finally Figured Out the Foot a Little Better

 The foot was somewhat of an enigma for me, even after taking I&I previously. Here is the lowdown.

#doubleentendre
#doubleentendre

In the LAIC/RBC pattern, the right foot is in a more supinatory position with calcaneal inversion; the left foot is pronated with an everted calcaneus.

These foot positions can create hallux limitus in both big toes for different reasons. The right big toe can be limited via active insufficiency if the first ray plantarflexes to touch the ground. This position would be a “deficit” equivalent to a decreased left straight leg raise secondary to an anteriorly rotated innominate. This compensation would also create a larger gap between toes 1 and 2 via abductor hallucis.

The left big toe is limited by passive insufficiency secondary to a pronated foot. The first ray is dorsiflexed because the foot is pressed into the ground.

Restoring big toe mobility must therefore follow a different progression than simply mobilizing great toe extension. The first line of business is to stabilize the calcaneus. If the calcaneus is moving all over the place and cannot adequately contact the ground, stability has to occur somewhere. Oftentimes this will occur at the mid to forefoot, promoting the aforementioned foot position.

We can create calcaneal stability via gastrocnemius inhibition to allow the heel to touch the ground:

[Side note: That squat was barefoot without my gelb splint or glasses. You have no idea how monumental that is for me.]

If your heels cannot touch the ground, you will never access frontal plane. If someone keeps losing hip extension or adduction in standing, think gastroc inhibition.

Then, we can create stability with good shoewear. Look for a stable heel counter as my Dad demonstrates below:

A stable calcaneus is needed because hindfoot position controls what occurs at the forefoot. The subtalar joint unlocks the forefoot during eversion and locks it during inversion. Foot intrinsic strength becomes meaningless if you can’t control frontal plane calcaneus movement.

Take that into account if you are a barefoot advocate. I’m totally cool with the idea of barefoot training IF you can stabilize your calcaneus and are not driven further into extension with your shoes off.

Comes prelateralized. Buy yours today.
Comes prelateralized. Buy yours today.

Once we have a stable calcaneus, addressing first ray position becomes critical. Oftentimes the first ray is good once you have the calcaneus, but if not we may need to build up the arch in the shoe or throw in some classic manual therapy to alter position.

Foot position can be extrapolated by testing hip abduction and adduction movement. If there is limited abduction, chances are an individual is overpronating. If the adduction drop is positive even after gastroc inhibition, there is likely a supination restriction.

If you perform the above steps and there are still big toe extension limitations, then big toe-oriented manual therapy sounds like a wise choice.

Some Neat TMCC Side Discussion

 You ever wonder why people stick out their tongue when performing a challenging activity?

Like oh I don't know...Maybe this guy?
Like oh I don’t know…Maybe this guy?

It has to do with tongue thrusting. One thrusts the tongue forward to create OA and neurological extension. This maneuver would help increase extensor tone, leading to improved force production.

It’s probably not a good idea to do that all the time.

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Many individuals with a narrow palette, and thus a narrow airway, require palatal expansion. We want the maxillary arch to look like a U more so than an A.

When we look at how to expand the palette, there are several different devices that can be used; ranging from most aggressive to least aggressive:

  • Rapid Palatal Expander (RPE): this is where you turn the key to expand the palette. = Bulldozer knocking down a tree.
  • Herbst appliance = car chained to a tree.
  • Alternative lightwire Functional Splint (ALF): Spreads the palette 2mm to reduce muscle tone. = A person holding a tree.
  • Tongue on the roof of a mouth = Dog peeing on a tree.

Hip Impingement Help

 Walking should allow for desirable acetabulum on femur (AF) and femur on acetabulum (FA) movement in three planes.

AF adduction ought to occur from foot strike to midstance, and AF abduction from midstance to terminal swing. The hip also progresses from external rotation to internal rotation up to midstance, then back to external rotation until terminal swing.

If these joint positions cannot be achieved secondary to the pattern, nociception from the hip joint can be produced by impingement regardless of closed or open kinetic chain activity.

There are three common types of impingement seen in the clinic, and PRI has implemented strategies to reduce the chance of these occurring.

Anterosuperior acetabular femoral impingement (ASAF)

  • Usually occurs on the left when attempting to shift into AF IR.
  • Demonstrates need for anterior glute med, so bias FA IR before shifting into AF IR.

Anteromedial femoral acetabular impingement (AMFA)

  • Usually occurs on the right when attempting to IR the femur or with posterior translation of the humeral head in flexion.
  • Reflects need of a right glute max.

Laterosuperior femoral acetabular impingement (LSFA)

  • Usually occurs on the right side when attempting to abduct. Described as a pinch below the iliac crest.
  • Needs to be able to abduct in left AF IR position.

That’s It

 There were so many other topics that were discussed here, but I wanted to provide some more in-depth discussion with some of my favorite topics covered. Get to a PRI course as soon as you can, as they continue to be the best in the biz.

Good times had by all.
Good times had by all.

Cantrellisms

  • “Madder than a wet hen.”
  • “You’ll learn one language in school and you’ll learn how to get patients better here.”
  • “What good does it do to strengthen a rotator cuff on a scapula that is not home?”
  • “If they can’t dance you’re going to have a hard time working with them.”
  • “A wink is as good as a nod to a blind mule.”
  • “Walking is a compensatory strategy.”
  • “Slicker than the center seed of a cucumber.”
  • “There’s no such thing as a left handed protocol.”
  • “Slicker than a peeled onion.”
  • “She’s grinning like a butcher’s dog.”
  • “Get a zone and 75% of patients get better.”
  • “Neuro always trumps orthopedic.”
  • “Everyone who wears flip flops is doing toe raises.”
  • “We should be smelling fried glute in a few minutes.”
  • “The spirometer doesn’t lie.”
  • “Screwed up as a soup sandwhich.”
  • “Slicker than a firehouse pole.”
  • “Only way you can get a reset is with a pause.”
  • “Why strengthen a rotator cuff on a skateboard?”
  • “If you just listen to country, you’re going to lateralize to the right.”
  • “I got no wrinkle in my britches and I’m fixin’ to shift.”
  • “Crooked as a goat path.”
  • “Hotter than a $2 pistol.”
  • “I don’t need to be at home depot all the time. Let’s do this.”
  • “Sweeter than sour with honey.”
  • “Nervous as a long tail cat in a room full of rocking chairs.”
  • “PTs write prescriptions to inhibit.”
  • “Quiet as a church mouse.”
  • “Once the toilet is flushed everything is gone.”
  • “Naw hell.”
  • “Well don’t just do something, sit there.”
  • “Did you see that? I just metabolized.”
  • “Hawkins-Kennedy? Neers? I don’t know what that is.”
The only time I've seen Mike nervous.
The only time I’ve seen Mike nervous.

Course Notes: PRI Craniocervical Mandibular Restoration

“The Head and Neck Runs The Show.” ~Ron Hruska

Hello, my name is Zac Cupples, and I have an addiction. I am addicted to attaining CEUs. But not just any CEUs, I want me some of that purple haze from the Postural Restoration Institute.

I got my fix and then some.

This past weekend I was at Endeavor Sports Performance in Pitman, NJ. I got to spend time learning about the neck and the cranium from none other then PRI founder, Ron Hruska.

From the get-go, Ron was adamant in saying that this class was his baby. That this information is what started it all.

And what I learned did not disappoint.

A bunch of happy addicts for sure.
A bunch of happy addicts for sure.

When I took Advanced Integration this past winter, I understood that we were affecting a system, but it didn’t really settle in with me until now. What we are predominately using to affect the nervous system is not specific muscles, but namely triplanar muscle families.

I am not trying to turn on the hamstrings, but I am trying remap the brain’s sagittal plane. I am not trying to turn on the IC adductor, but remapping frontal plane adduction to send me into left stance.

Similarly, we can affect these movement planes with cervicocranial mandibular muscles. It is just another location in the system to which sensory input is applied. Though seeing what outputs resulted will leave you just as surprised as your patients and cleints.

Watching Ron affect a person’s mobility throughout the entire body by manipulating a bite left me awestruck.

You do not realize the power of the human body, the nervous system, and autonomics until you see alterations at seemingly irrelevant areas creating system-wide changes.

I have been so excited to utilize this information clinically, so here is what I learned.

The Boomin’ System

LL is so down with PRI.
LL is so down with PRI.

The introductory courses focus predominately on testing/affecting certain body regions. When you move up to Impingement and Instability, the system slowly ties together via more bottom-up influences.

In this class, we see how we can influence the system from a top-down perspective. We have a new diaphragm that we work with called the maxilla. As we phase through respiration, the maxilla, albeit to a lesser degree, expands and domes via eating activities.

The goal then, is to maximize maxillary position to create thoracic flexion via the sphenoid.

Sphen-what??!?

Yes, you read that correctly, the sphenoid. We played with cranial bones quite a bit in this course. Much like the rest of the body, when I am in right or left stance the cervico-cranial- mandibular bones assume particular positions.

If you have read my reviews on PRI’s myokin and pelvis courses, visualizing cranial positioning will be a breeze. The craniomandibular system mirrors the pelvis (the temporal bones), sacrum (sphenoid) and femur (mandible). This picture alone did it for me regarding similarities.

Looks pretty similar to me I'd say.
It’s the same you guyssssssss!

As you can see, the above bones and corresponding motions are quite similar.

When I am in right stance (aka the pattern), my temporal bones and sphenoid are positioned as follows:

  • Left temporal bone: Flexed and externally rotated; an inspiratory position.
  • Right temporal bone: Extended and internally rotate; an expiratory position.
  • The sphenoid: The left-most portion is anteriorly rotated, and the right-most portion is more posteriorly rotated.

Continuing down the pathway, the mandibular region positions as follows:

  • The maxilla orients right.
  • The mandible laterally deviates to the left.
  • The left TMJ capsule: Posterior/medial  (retruded mandible)
  • The Right TMJ capsule: Anterior/lateral (protruded mandible)

And the cervical spine orients as such:

  • Left OA is extended and sidebent to the left.
  • Right OA is flexed and right rotated.
  • The cervical spine is oriented right and left side bent.
  • C2-C6 are flexed.
  • C7-T8 are extended.

An easy way to observe this normalcy, aside from the tests we will do, is to look at someone’s face. Often the following observations can be noted:

  • Full right lateral face.
  • Right temporal indentation compared to the left.
  • Forward, opened, wider, larger right orbit.
  • Right eyeball protruded, left eyeball retruded.
  • More visible left flared ear.
  • Larger and more opened right nostril.
  • Increased distance between side of face and lateral ocular angle on the right side.
  • Elevated right eyebrow.
  • Mandible slightly deviated to the left.
  • Tongue is thicker on the right side, and tends to stick out toward the left.

aka Gary Busey

It is insane how right you are Bill.
It is insane how right you are Bill.

So, our goals here are to protrude the mandible, retrude the cranium, flex the sphenobasilar system, restore cervical lordosis, restore “normal” resting bite, and slight OA extension so the neck is able to turn.

I know I am talking a lot about cranial movement, which I am certain the craniosacral police may come calling. I don’t think that cranial motion is necessarily why we see such changes with these techniques (though cranial bones do move, see here and here).

What seems more plausible to me is the fact that the trigeminal nerve covers so much of this area and is so interconnected towards many body regions.

Moreover, look at the face’s representation in the somatosensory homunculus. It’s huge. Therefore, I feel any input to this region can lead to profound neurological effects.

If you want some literature on how altering bite influences the system, I would check out the following studies here, here, and here (part of my PRC application), as well as my good friend Lance Goyke’s blogs here and here on dentition and foot posture

That’s a Nice Butt You Have on Your Cranium

Now obviously, the craniocervical bones do not just become positioned like this on their own. We have a new muscle chain that helps us achieve right cranial stance called the Right temporomandibular cervical chain, or right TMCC. It involves the following muscles:

  • Longus capitis
  • Superior oblique
  • Rectus capitis posterior major
  • Rectus capitis anterior
  • Temporalis (anterior fibers)
  • Masseter
  • Medial pterygoid

To oppose this chain, we will utilize some of the following muscles:

  • Sagittal repositioners: Left SCM and upper trap
  • Frontal plane abductors: Left rectus capitis anterior and lateralis; longus capitis
  • Frontal plane adductors: Temporalis
  • Transverse plane: Right rectus capitis posterior major and minor, superior and inferior oblique
  • Internal rotators: stylohyoid, styloglossus, stylopharyngeus, left lateral and medial pterygoids.
  • Integration (aka da abzzz): longus colli

If you have taken Myokin, again we can try to make some comparisons to lower quadrant muscles

  • Temporalis = gluteus medius
  • Lateral pterygoid = ischiocondylar adductor
  • Longus colli = Internal obliques and transversus abdominis
  • Suboccipitals = glute max
  • SCM = Hamstring

The Big 3

The only real big three are Jordan, Pippen, and Rodman. However, this class shows us a big three that help us get into a Left TMCC, or more functionally, left cranial stance. And these three muscles are utilized to influence certain bones:

  1. Lateral pterygoid – sphenoid
  2. Temporalis – temporal bone
  3. SCM – temporal bone
I want you to use those Bulls of your cranium.
From left: SCM, temporalis, lateral pterygoid

What predominately moves in this system is the sphenoid. This bone is very thin and airy, thus making it one of the more mobile cranial bones. It is also a very rich location for nervous tissue. The glossopharyngeal, vagus, and spinal accessory nerve all pass through this bone. More ammo to see the cranium as a neurologically-rich area, thus potentially impacting multiple body systems.

Tests

To assess this position, we are not palpating cranial position. Instead, we look at the neck and jaw via:

  1. Cervical axial rotation (total cervical spine rotation)
  2. Mandibular lateral trusion with protrusion

Typically, in the right TMCC pattern, you will see limited axial rotation to the left and decreased right mandibular lateral trusion. These limitations are due to the spinal and mandibular orientation mentioned above.

There are instances in which you may have one but not the other, which PRI would consider “patho.” For example:

  • Decreased Right trusion + non-limited Left axial rotation = OA laxity.
  • Limited left axial rotation + Increased right trusion = TMJ hypermobility.

Treatment

There was actually not many new treatment techniques in this course, as many other activities target the planar muscle families we are trying to use. But I was exposed to a couple new things I really enjoyed.

My favorite exercise from the class focuses on performing a TMCC movement while performing the exact opposite pattern at the thorax and pelvis. So a Left TMCC, left AIC, right BC technique:

The show for me was the manual technique we went over, called the frontal-occipital hold. I had been exposed to this technique before, but learning how to properly perform it has made a huge difference.

It doesn’t seem like much, but clinically I have seen big changes with several of my patients. At this course in particular, Ron was able to increase mandibular opening on a classmate from 30mm to 46 mm. The change in motion throughout the rest of this patients body, as well as his general affect was unreal.

You don’t have to get super-fancy with these techniques, as even performing simple jaw exercises can have profound effects.

Reinforcements

We also learned a couple new reference centers which you can utilize to further maintain changes. These include:

  • Posterior mid-neck
  • Teeth

The more you can feel and contact these areas, the better TMCC neutrality can be maintained.

My other favorite ways to maintain neutrality include:

  • Keeping tongue on roof of mouth behind upper incisors.
  • Keeping teeth slightly apart throughout the day.
  • Make a clucking noise on the palette with your tongue throughout the day.
  • Touch your back upper molars on either side with the tongue.

When to Refer and other Dental Fun

Although I was pleasantly surprised by how much we clinicians can affect this pattern, there are certain cases in which you will need extra help. Here is where dentists come into play.

Referring out usually occurs when structure maintains the right TMCC pattern. It is in the following instances in which you may need to enlist a dentist to maintain neutrality:

  • Can’t contact molars after neutral
  • The jaw and mandible open towards the side of a displaced disc.
  • Really strong open bite.

Not every dentist is going to possess the skills necessary for maintaining neutrality, so the following qualities ought to be sought for in a dentist:

  • Look for a craniofacial dentist.
  • One who uses Alternative lightwire fixation (ALF) splints for palette expansion.
  • Should also be familiar with Elastic Mandibular Appliances for airway management.

Other splints that are good to utilize throughout the day include flat occlusal plane splints. These splints help free up occlusion while working on a PRI program.

When looking for one of these splints, you want diurnal mandibular acrylic splint for two reasons. First off, if your splint in on the maxilla, the mandible is going to have a tendency to create contact by biting. A mandibular splint keeps the jaw relaxed. You also want the splint to be acrylic because we have a tendency to chew plastic, which again would increase jaw tension.

Sometimes pterygoid exercises aren't enough.
Sometimes pterygoid exercises aren’t enough.

 (in)Famous Ron Quotes

On Systems

  • “We are built asymmetrical so we can move.”
  • “Peripheral issues are not working in subsystems.”
  • “I can’t wait to see the day where you succeed at failing [to get into extension].”
  • “90% of patients have a degree of dizziness.”
  • “When you start to play with the body, you play with everything.”
  • “If I have flexion, I can have fun at a party without any liquor.”
  • “If you can’t communicate, you cannot succeed.”
  • [After restoring shoulder and mandibular movement with cranial manual therapy] “Welcome to my world. I am out there alone and I would like some friends.”

On cervical-cranial mandibular Function

  • “I don’t want you to suck at sucking.”
  • “Sucking reduces knee pain.”
  • “The first orthotic you should use is your tongue.”
  • “Cervical Traction is reverse autonomics.” [because cervical lordosis is minimized]

On Muscles

  • “If you want to swallow, you want a levator.”
  • “SCMs take over the world and you lose frontal plane.”
  • “Pterygoids are your built-in CPAP.”
  • “If you want to be orthopedically minded work on a butt muscle and say a lot of rosaries.”
  • “Lats rotate when other areas don’t.”
  • “If you want to treat lats you better move bregmas.”

On the Cranium

  • The head is the fifth extremity.”
  • “The sphenoid knows what the entire body is going through…it owns you.”
  • “Your temporal bone owns trigeminal neuralgia.”
  • “Atmospheric pressure is regulated by a temporal bone.”
  • “The Cranium loves Bob Ross.” [frontal plane = creativity]

On Respiration

  • “People who can’t breathe through a nose have no lips.”
  • “Mouth Breathers are floor addicts.” [Look at ground to get cranial flexion]
  •  “Got nose.”
  • “Oxygen is the new modality.”

On Teeth

  •  “Every tooth you lose makes you unstable.”
  • “Chewing is gait 101.”
  •  “Teeth are passengers on a boat moved by muscles. The way they come out depends on the torque put on the tooth.”
If a picture of Ron in a meat dress being painted by Bob Ross doesn't scream frontal plane than nothing does.
If a picture of Ron in a meat dress being painted by Bob Ross doesn’t scream frontal plane than nothing does.

The Year of the Nervous System: 2014 Preview

It’s All Part of the Plan

And if you see my course schedule this year, the plan is indeed horrifying.

joker

I wanted to write a post today to somewhat compose my thoughts and plans for this year, as well as what I am hoping to achieve from the below listed courses.

Because of the course load and some of my goals for the year, I am not sure what my blogging frequency will look like. I have begun to pick up some extra work so I am able to attend as much con ed as I do.

Yes, this will be me from time to time for now.
Yes, this will be me from time to time for now.

The Amazon affiliate links that I don’t get money for because I live in Illinois simply cannot pay for classes :). I am just putting these links up here because I want to encourage you to read these books on your own. Use my site as a guide through them.

Big Goals

My biggest goal for this year is to successfully become Postural Restoration Certified (PRC), and my course schedule below supports this goal.

The amount that I use this material and the successes that have come along with it simply compel me to become a PRI Jedi. I see the PRC as a means to achieving this goal.

The application thus far has been quite time-consuming. There are a total of 3 case studies, 5 journal article reviews, and tons of other writing that has to be done. Couple that with studying the material, and I have had a very busy year.

I also hope this year to start offering some online training at some point. I do some personal training on my own in my free time (ha), and would like to extend my services to people who are not near me. This would come complete with a full skype evaluation and unlimited access to me via email for all your questions, comments, concerns, and complaints.  If anyone is interested, please contact me at cupplesperformance@gmail.com

This will NOT be you on my programs.
This will NOT be you on my programs.

Without further ado, here is the course list.

Course List 2015 aka “The Year of the Nervous System”

I have dedicated this year to maximizing my understanding of the most powerful way to get into my patients, here is the lowdown

January 17th-18th – PRI Pelvis Restoration, St. Louis, MO

Been so looking forward to this class. Here I hope to learn about decreasing extensor tone in those people who use it as their protective pattern. Extension is what gives us power in response to defend from threat, this course will help you turn it off when you need to.

February 8th-9th – PRI Cervical-Cranio-Mandibular Restoration, Pitman, NJ

There are several patients that I just seem to have a harder time with. People with neck pain are one of them. Moreover, there are some patients who I just can’t seem to get fully neutral from a PRI perspective. I am hoping to learn to what extent I can affect the neck and above to help my patients achieve better function.

February 15th-16th – Explain Pain, Atlanta, GA

I have already taken this course once, but the man, myth, and legend David Butler is teaching this version. EP is his baby, his muse. If I won’t ever be able to see Led Zeppelin live, interacting with Butler would be the next best thing.

Total rockstar in my eyes.
Total rockstar in my eyes.

March 1st-2nd – Therapeutic Neuroscience Education: Educating Patients About Pain, Naperville, IL

I have been fortunate enough to chat with Adriaan on multiple occasions, and have the pleasure of hosting him where I work. It will be nice to get his perspective towards pain education. Adriaan was who I took Explain Pain with, and I will be curious to see how his thought process has changed since a couple years ago.

March 29th-30th – PRI Postural Respiration, New York, NY

Another re-take course for me. But this time, I have much more experience with the system. I hope my understanding will be so much more enriched. Plus, I get to learn it from Ron. Anytime you can learn from this man please do.

April 26th-27th – PRI Vision, Grayslake, IL

The motor system is not the only thing that can put up defense mechanisms in response to threat. The visual system changes as well, and in many cases can drive one’s protective postures. I need to know why and how.

May 2nd-4th – Dermoneuromodulation, Chicago, IL

The skin is such a sensory-rich organ that I need to learn more about it. And who better to learn it from then the master-ectodermalist Diane Jacobs. I have yet to take a true hands-on course, and if I can learn a pain-free way into the nervous system, then sign me up.

Hopefully I can teach her some therapeutic Microsoft paint techniques in return 🙂

True dat
True dat

June 7th-8th – PRI Integration for the Home, Lincoln, NE

Sometimes the PRI movements can be very challenging for those who are older. I want to know how my man James Anderson gets this population to perform at the high level he does. I want the baked goods!

Also during this week I plan on netting some observation time at the Hruska clinic. Details to follow.

August 9th-10th – PRI Myokinematic Restoration, Indianapolis, IN

I took this class last year, and want to be as prepped as possible for the PRC. Besides, Indy is my Mecca. I have so many good friends there that I cannot pass up a chance to hang at IFAST.

October 18th-19th – Neurodynamics and the Neuromatrix, Buffalo, NY

With two rounds of Explain Pain and Mobilisation of the Nervous System under my belt, what better way to put the classes together? Plus I am hoping to get my man Erson Religioso to come so we can hang out (hint hint).

November 1st-2nd – NOI Clinical Applications: Lower Limb and Lumbar Spine, Chicago, IL

I am going to this one mainly to cleanup my techniques and though process, as well as learn a little more about the less talked about nerve tracts (that darn saphenous nerve).

November 21st-22nd – PRI Integration for Baseball, Clearwater, FL

Florida in November…no brainer 🙂

But seriously, getting little snippets throughout my previous classes about what they will be teaching here has me intrigued.

Most of PRI deals with gait, which if we talk DNS is a contralateral pattern. Here my understanding is how PRI will approach the ipsilateral patterns. They will also introduce a test for the thorax, hopefully giving me a nice adjunct to the Hruska Adduction lift test.

December 4th-9th – Advanced Integration and PRC testing, Lincoln, NE

AI was such a game changer for me this year that I cannot wait to take it again. There are so many nuances I want reinforced and so many questions answered.

Moreover, the PRC test is going to happen, and learning in close proximity with Ron, James, and Mike is an opportunity I simply cannot pass up.

C’est Fini

So there’s the plan for this year. What thoughts do you have? What’s on your con ed radar for the year? Comment below.

What I use to find the best con ed courses there are.
What I use to find the best con ed courses there are.