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.

 

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) and extension drop (Thomas test).

The adduction drop will look at your capacity to get into the sagittal and frontal plane, and the extension drop test will look at your anterior hip ligamentous integrity.

A positive extension drop is a good thing if you are in the LAIC pattern. It means you didn’t overstretch your iliofemoral and pubofemoral ligaments. Well done! The reason why this test is not a hip flexor length test has to do with the femur’s position. In the pattern, the femur is positioned in a state of internal orientation secondary to an anteriorly tipped and forwardly rotated pelvis.

Due to this orientation, the femur must be externally rotated during performance of an extension drop test. This would put the psoas on slack. If you still have a positive test, then we know the anterior hip capsule is intact because that’s the only thing holding the hip up.

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.

Course Notes: Advanced Integration and PRC Reflections

I Passed

I officially became a Jedi this past December after retaking Advanced Integration and going through the Postural Restoration Certified (PRC) testing.

Both were a wonderful experience in terms of learning new concepts and fine-tuning old ones.

Since I have retaken this course, I will not go into huge detail in terms of the material covered (if you want detail, read last year’s AI notes here, here, here, and here).

Instead, I will reflect on a few concepts that really hit home for me (No, i’m not saying what we did at the PRC)!

Enjoy.

Hanging with the Jedi Masters
Hanging with the Jedi Masters

 Extension is Evolution

Extension is what allowed our brains to develop because it brought us to two legs.

The big extenders: psoas, paravertebrals, lat, QL, capitis

Extension given us more but comes with a cost. As we continue to extend, we increase system demands. Extension will likely be a necessary adaptation to live in the world we are creating.

I’m scared to see what the future looks like.

Batman circa 2070. Complete with myopia, anxiety disorder, and constipation...Not sure why I said the same thing three times (sorry, wrong course).
Batman circa 2070. Complete with myopia, anxiety disorder, and constipation…Not sure why I said the same thing three times (sorry, wrong course).

Position

Refers to triplanar position of the body. Neutrality is the state of rest and transition zone from one side to the other. We want this most of the day, but can’t expect this to occur all day. We want to establish a rhythm in and out of neutrality in alternating and reciprocal function.

The alternating and reciprocal rhythm has alternate appendages on either side of the body. When the left leg is in front, the right leg should be back.

In right stance, the appendages take the following positions:

  • Legs – right back, left forward
  • Arms – right forward, left back
  • SCMs – Right back, left forward
  • Lateral pterygoids – right forward, left back
  • Extra-ocular muscles – right back, left forward

In left stance, the above positions are reversed.

Oftentimes one or many of these appendicular positions is flipped. This flipping is when you have defensive patterning (LAIC/RBC/RTMCC/PEC).

Aka Phil Collins-ing
Aka Phil Collins

Position is More than the Body

Position extends beyond body states. Position reflects who you are.

There was a table regarding human asymmetrical concepts present in this year’s manual that listed characteristics of neutral versus PEC individuals.

It blew me away because it very well matched my personal transition; especially comparing how I am now to when I was a young lad. Check this out.

Neutral PEC
Movement/motion Rest/locked
Loosening Binding
Arbitratiness Order
Accident Law
Live, create, play Work, formal, rigid
Lead/risk taking Follow
Freedom Constraint

I’ll probably be in jail painting pretty pictures once my wisdom teeth are pulled.

 Septums and Chambers

Septums are partitions in our bodies that separate chambers. For example, the diaphragm is a septum between the thoracic and abdominal chambers. These septums stiffen with flexion and loosen with extension.

We want septums to be tight, as septal tightness allows for chambers to expand, shift, and rotate. When a chamber can’t expand, it shall become loose.

Yesh indeed
Yesh indeed

If you want a tight septum you must be able to flex. Flexion is what gives one access to shift and rotate.

The normal respiratory cycle alternates between chamber and exoskeletal dominance. Upon inhalation, the exoskeletal system becomes unstable, but chamber pressure increases. When exhalation occurs, exoskeletal stability increases and chamber pressure decreases.

Thinking about this alternation clinically, one who lives in a constant state of inhalation (i.e. extension) will stay upright via chamber pressure. Stability is passive. On the flipside, one who spends more time exhaling (i.e. flexion) must keep upright stability via active elements

Poop Talk

The rectum is shaped somewhat like a cone to which a pressure gradient for defecation occurs by gravity and peritoneal cavity shape.

Our natural human asymmetry is necessary to mobilize abdominal contents. Our iliums act as pumps for the rectum, shifting contents back and forth with each step we take.

If we only have access to one phase of gait though…things get shitty.

Puns all day
Puns all day

Create with Your Arms

Hands should be free to reach and create, but when we are in a protective pattern, inability to reference the ground through our legs leads us to find reference elsewhere.

Like JOSPT, the extension of references.
Like resorting to JOSPT, the extension of references.

In some individuals, the arms can act as a reference center to hold us upright. This occurs most notably when we lack transverse plane activity. If you see these behaviors, think need for transverse plane:

  • When one writes, they push the pen into the table as opposed to gliding it across paper.
  • Nail biting.
  • Hands in pockets (guilty as charged).
  • Fist clenching.

When you have people who cannot create with their arms, being able to feel the ground is one of the best things you can do. Ground push-off is what reduces the reference needs of the arms.

It’s Not Illegal for your Right Ab Wall To Engage

One of the biggest mistakes I made was losing a right zone of apposition (ZOA).

Big mistake
Big mistake

A slight right ZOA is necessary when creating right apical expansion. The LAIC/RBC/RTMCC pattern dictates the ribs on the right are closed down. Airflow ought to be used to open up these ribs.

However, if I lose the ZOA on the right by letting my ribs flare and over-externally rotate, the right ribs will stay compressed. All that will be stretched is the right ab wall.

Conclusion: exhale and keep the ribs down and in on both sides. Then upon inhalation, a stretching sensation should be felt in the right intercostals. You won’t take in much air.

It is Illiegal to Overflex

We don’t want turtle humps, as this would be the same as creating excessive kyphosis in standing.

Instead, what we want is appropriate kyphosis via posterior mediastinum expansion. Get a ZOA, keep the ZOA, then inhale.

Mirrors are Cool

We learned some neat tricks you can do with a mirror. The mirror takes away visual reference by disassociating what is being seen from what is being felt.

This strategy is especially useful for people who can’t find and feel muscles on one side but can on another. Check out the video below to see an example.

Vision

Public service announcement: When getting your eye exam, ask your optometrist to make sure that you are not overcorrected and that your eyes work together or are balanced. These changes alone will make visual information coming into your brain less threatening for the system.

Foot Fun 

I came with a new appreciation of the subtalar joint. It’s a triplanar ball and socket-like torque absorber that creates pronation and supination.

This rotational force is not always occurring by the leg muscles however. In the closed chain, the opposite hip swinging forward creates supination in the foot. The effect is like a ratchet (twister is the pelvis, stationary end is the lower extremity).

The first helpful visual on zac.cupples.com
The first helpful visual on zac.cupples.com

This rotational component is one possible reason why many orthotic therapies can fail. A foot orthotic must be able to return the entire lower extremity to the center of the frontal plane (i.e. neutral).

Contrary to the haterz, orthotics will not weaken the foot. What they are made to do is change proprioceptive inputs that can have an effect on motor learning. Orthotics can allow one to find and feel muscles they may have not felt before.

It’s a different sensory experience, just like anything you wear is.

Even though PRI likes its orthotics, you may not always need shoes. Sometimes you can gain greater proprioceptive feedback to sense the floor barefoot. It’s going to be person dependent.

The verdict? Wear many different shoes and go shoeless occasionally. Give your dogs variable sensory inputs.

Infamous Ron Quotes

  • “If you’ve got rhythm you’ve got a diaphragm.”
  • “You should be moving so sinuses can drain snot.”
  • “If your gut is moving the bowels in your lungs are moving.”
  • “You have a center of your body…And I’m going to do this a lot…But it’s not the center of your body.”
  • “You have to handle the big G in some way.”
  • “What is this guy nuts? I am nuts.”
  • “Do something to become alive.”
  • “Wear different shoes everyday and you’ll probably poop.”
  • “If you cannot exhale you are probably dead.”
  • “Is your septum tight? Mine is.”
  • “If you don’t own yourself you can’t be kind.”
  • “I gave you these tests just so you would wake up.”
  • “It’s cool to be twisted.”
  • “If you suck at twister you can’t uncoil.”
  • “I like to break the law once in a while.”
  • “If you are going to do PRI, underbreathe.”
  • “Pain distorts where you are at.”
  • “Gosh, all my patients are snakes.”
  • “Quadratusitis. It preceded ebola.”
  • “The more references you have the less obese you will be.”
  • “Curvatures run the show.”
  • “Really? We’re going to fight to move a joint through a range?”
  • “Leave the body alone unless you really have to do something.”
  • “Can you imagine me in black spandex? Or a penguin?”
Well, not the penguin I guess...
Well, not the penguin I guess…

Lori-isms

  • “I have her in good shoes. She knows I have an attitude.”
  • “That old bald guy this morning…”
  • “Oh she’s shaking like a leaf.”
And Lori can make leaves shake quite vigorously :)
And Lori can make leaves shake quite vigorously 🙂

Cantrellisms

  • “I’m not afraid to say I don’t know.”
  • “These type A patients, and I don’t mean Hong Kong Taipei.”
  • “Neutrality is nothing. You need to be able to work with it.”
  • “It’s not illegal for your right ab wall to engage.”
  • “No! I’m sorry, just trying to find the floor on the left side.”
Cuz sometimes ya just don't.
Cuz sometimes ya just don’t.

Great James Quotes

  • “You want to know why? Cuz Ron happens.”
  • “Extension is not bad if you can manage air and chains.”
  • “You can train everything but you don’t want to overtrain discord.”
  • “If you can’t trunk rotate you can’t ZOA incorporate.”
I really need to start selling shirts...
I really need to start selling shirts…

 

 

The End of Pain

I’m Done Treating Pain.

Yes. You read that correctly. I’m over it.

Several different thoughts have crept into to my mind sparked by what I have read and conversations I have had. I would like to share these insights with you.

I remember when I was visiting Bill Hartman Dad a few months ago and we were talking about a specific treatment that is quite controversial in therapy today. He said something that really resonated with me:

“Maybe they measured the wrong thing.”

This sentiment was echoed in “Topical Issues in Pain 1” by Louis Gifford. Check out this fantastic excerpt:

“Thus, pain can be viewed as a single perceptual component of the stress response whose prime adaptive purpose is to powerfully motivate the organism to alter behavior in order to aid recovery and survive.”

Notice what I bolded there. Pain is a single component of the stress response. Not the stress response. Not a necessary component of the stress response. Just one possibility.

Anything is possible!!!!!!!
Anything is possible!!!!!!!

Why do we place so much importance on pain?

Many proponents of modern pain science (myself included) often use this statement against individuals who are over-biomedically inclined:

“Nociception is neither necessary nor sufficient for a pain experience.”

Agreed, pain is not always the occurring output when nociception is present. That said, pain is only one of several outputs that may occur when a tissue is injured. Just because pain is absent does not mean other outputs are also absent.

Many different outputs can occur when an individual is under threat.

Let me propose a new quote to those who focus solely on pain.

“Pain is neither a necessary nor sufficient output of the stress response.”

Why should we limit ourselves to only treating pain? Why should we limit ourselves to only treating outputs? (Spoiler alert, we can’t treat outputs, change them) I have a better idea.

Today, I start treating a human system under threat.

The Threat Matrix

 Dad showed me this great editorial here in which Eric Visser expands upon Melzack’s original pain neuromatrix.

Visser calls this idea the threat matrix. To simplify the idea, threatening inputs from the body and the environment enter the system, are scrutinized by the brain, and then the desired output to combat the threat occurs.

Input –> processing –> output

This framework explains how any output, desirable or undesirable, can occur from a stressful input.

Let’s apply this to an example that we have all been through; a breakup with a significant other.

Your significant other decides to leave you, how do you feel?

The answer depends on the individual. Some folks may feel depressed. Some may feel anger.

Some may even experience pain.

Or you may throw a party in your ex's name and not invite them
Some may throw a party in their ex’s name and not invite them

These feeling are all outputs that occur as a result from an input (i.e. the breakup) that disrupts homeostatic balance of the human system. The outputs that occur are the ones that the brain determines best aid the individual in recovery and survival.

Let’s now take this thought to the therapy realm. I sustain tissue damage and nociceptive information travels to the brain to be scrutinized. What output(s) could occur? Let’s think of a few possibilities.

  • Pain
  • Sympathetic dominance – increased sweat production, heart rate, blood pressure, etc.
  • Motor responses to protective patterns
  • Endocrine alterations in gut/reproductive function
  • Increased/decreased immune activity
  • Fatigue
  • Anxiety
  • Depression
  • Fear
  • Yada yada yada

All of these could occur, some of these could occur, or none of these could occur. The response to the offending input is going to depend on the individual’s brain scrutinizing the situation.

One could argue that a nociceptive event could lead to someone developing anxiety and poor immune function without ever experiencing pain if that is what the system feels best aids in survival.

Nonspecific Effects my Arse

There are many treatments out there that people deem worthless because research demonstrates minimal effects on pain compared to placebo. If someone gets better with this intervention, we deem that nonspecific effects led to the change in pain.

I call bullpoop…sort of.

Utter bullpoop
Utter bullpoop

Nonspecific effects could be a contributing factor to someone benefitting from a particular treatment, but the problem with most pain research is that often pain level is the only thing that is measured.

If pain is only one possible output of a system under threat, how do we know that a treatment didn’t affect a different output?

Answer: We don’t because it wasn’t measured!

Let’s take a controversial treatment for example: dry needling.

Talk amongst yourselves if verklempt
Talk amongst yourselves if verklempt

Some say it works wonders for pain, some are vehemently opposed, and research is mostly mixed. What do we do?

Perhaps both camps are wrong. Why? Pain is the only output being discussed.

What if this whole time, dry needling worked because it altered inputs coming in from the immune, autonomic, or [what the hell evahhhh] system, which led to changed output from this system primarily with pain output altered secondarily? And here is the kicker; the intervention only works if these systems respond as well as our pain system under a particular threat.

Well we don’t know that because we didn’t look at it. But looking at multiple systems when an intervention is implemented may give us more explanatory power as to why certain treatments help certain individuals. With this information, treatment could be streamlined and implemented.

Endless Possibilities

Making pain our only concern to treat severely limit our capacity to help individuals. If we think of treating the stress response itself, we open up a huge realm of issues our interventions may affect.

If you take a look at the book “Spark” and the corresponding research, we see how exercise can alter many different outputs.

Why can’t rehab folks be a piece of this puzzle? It does not seem unreasonable to me that we could get referrals for anxiety, depression, or whatever output the stress response creates.

Some really know how it feels to be...
Some really know how it feels to be…

Strategically implemented exercise can help alter the stress response. That possibility makes me so hopeful for our professions.

How can one best assess a system under threat?

Assessing Threat

If clinicians are to assess if an individual is undergoing a chronic stress response, we need to find a reproducible methodology that gives us this information. We must look at the human system from the input/output standpoint.

There are several outputs that can be measured to assess an individual’s homeostatic state:

  • Blood pressure
  • Heart rate
  • Respiratory rate
  • HRV
  • Blood work
  • Other specific medical tests

These are all great tests that can assess the amount of system stress an individual is undertaking. That said, I feel there is an even simpler method of assessing the stress response:

Our physical examination

But not patho
But not patho

Assessing the stress response begins with the subjective examination. This piece of the clinician-patient interaction helps us assess potential offending inputs as well as individual processing.

If we come across red or yellow flags, we can easily refer out to providers who can deal with that piece of the stress response. Here is where a psychologist, surgeon, oncologist, other medical professional can come into play. These individuals can alter the offending inputs or help influence processing that therapists and the like may not be able to touch.

There are always exceptions to what you wouldn't touch with a 10 foot pole.
There are always exceptions to what you wouldn’t touch with a 10 foot pole.

Let’s say we get through our subjective and we screen out that the above professionals do not need to be a part of this person’s care. Let us now proceed to our objective examination.

Assessing movement may be the simplest way to assess an individual’s stress status.

If we are to provide the “ideal” physical examination, we need to perform tests and measures that best differentiate a stressed from nonstressed individual.

To undertake this task, we need to have a few assumptions about what a nonstressed individual looks like. Let’s call this individual the “adaptable human.”

  • The adaptable human will have desirable multi-system variability. That is, human systems can perform as needed under certain situations without being “stuck” in a particular range. For example, blood pressure should stay lower when at rest and rise when performing physical activity. When blood pressure remains high at rest and with physical activity, that individual possesses system rigidity.
  • The adaptable human will have desirable multi-system capacity. That is, human systems can tolerate prolonged stressors without faltering. For example, a human can perform longer durations of physical activity with blood pressure remaining in levels that would not threaten one’s life.
  • The adaptable human will have desirable multi-system power. That is, human systems can tolerate intense stressors without faltering. For example, blood pressure can reach a desired level to allow for a particular physical activity to occur.

Our examinations ought to assess these three qualities: variability, capacity, and power.

Of the three, variability is most fundamental because almost every healthy human system functions in the manner. The movement system is no exception to this rule.

Movement variability, the ability to move in three planes, is the simplest reflection of this concept. A nonstressed system will possess movement variability. A stressed system shall become rigid and lose triplanar mobility.

Think to the last time you were stressed. Did your muscles tense or relax? As muscles tone increases, range of motion decreases. Assessing movement variability is an easy way to assess the general tone an individual has, and I speak more of why this notion is favorable here.

To assess variability, our examination must:

  • Look at the entire individual’s body
  • Cannot have bias toward one output (e.g. pain)
  • Must be reproducible and predictable

First, let’s look at popular rehab systems that I feel would not work in this instance and why.

  • Maitland: Biased toward altering one output (pain); segmental in nature.
  • McKenzie: Biased toward altering one output (pain); segmental in nature.
  • SFMA: Not necessarily biased toward one output, but does not look at entirety of human movement. Only two movement planes are assessed. Cannot see if an individual has variability in the frontal plane.
  • DNS: Wait? Do they even assess?

 

Just when you thought I couldn't diss DNS
Just when you thought I couldn’t diss DNS

I shall let my bias now creep in as I suggest the current best model we have for movement variability is PRI.

There are several reasons why I think PRI is currently the best model to assess threat:

  • It is not biased toward altering one output, as movement rigidity can occur along with several other outputs besides pain.
  • The entire human movement system is assessed in three planes.
  • The protective patterns one undergoes in threat are predictable and similar for all individuals.
  • When one deviates from these patterns, likely pathology had to be created in order to do so.

If an individual can produce nonpathological triplanar movement throughout his or her body, then movement variability is present. A movement system under threat will not have this capacity. A threatened movement system will become rigid.

Establishing movement variability is our primary way to reduce threat-response outputs.

If undesirable outputs remain once movement variability is established, then we know other interventions must be given to address these areas.

  • If pain is still present, then previously mentioned assessment systems hold value, as does graded exposure.
  • If psychosocial outputs are still occurring, we utilize therapeutic neuroscience education or refer to individuals that can address other factors.
  • If one has issues coming from another system, we refer to a practitioner that treats that system.
  • If one cannot perform a task well, then we build capacity and power.

The point being, once movement variability is restored the rehab clinician’s job for the most part is done.

The treatment is done so I guess I'll be leavin'
The treatment is done so I guess I’ll be leavin’

Movement freedom through triplanar inputs to establish variable motor behavior is the simplest way to let the brain know that an individual is not under threat.

A Call to Arms

 So I challenge you, my reader, to respect but look past pain. Look past the output. Let’s instead shift our focus to treating an individual who is under threat and stressed.

If you can attenuate threat with your current skillset, and refer to others who do the same with other skills, a much larger population can be helped.

Let’s continue to push our limits!

Uhhhhhhhhh
Uhhhhhhhhh

 

 

 

 

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

 

Course Notes: PRI Integration for the Home

The Pilgramage

One of the many reasons I was drawn to make the trek to Lincoln was to experience my man James Anderson’s original affiliate course.

I always enjoy hearing James’ perspective on PRI, and he did not disappoint here.

The course felt like an Impingement and Instability with a bias towards the geriatric/chronic pain populations. Some might argue that James is the king at implementing PRI here.

You'll have to ask James to do his Elvis impersonation next time you see him.
You’ll have to ask James to do his Elvis impersonation next time you see him.

I really admired James saying throughout the course that the Geriatric population houses his favorite athletes, and they really are.  High performance at any task, be it sprinting 100 meters or walking to pick up the mail, require similar alternating and reciprocal components. We still go after the same pieces to achieve different goals along a continuum.

So let’s dive into this high performance course for some high performing individuals.

PRI 101…or at Least the Pieces You Didn’t Get from My Other Reads

 The affiliate courses have a huge introduction that gives an overview of PRI principles, namely the Left AIC and Right BC patterns.

I’m not going to go through all the nitty gritty as this course did, but instead I’ll review concepts that James cleaned up for me. Think of this post as an in-depth FAQ.

If you want to learn more about the left AIC, you might want to read the course notes on Myokinematic Restoration and Pelvis Restoration.

If you want to learn more about the Right BC, then read my Postural Respiration notes.

Because we know what happens when we repeat something too many times.
Because we know what happens when we repeat something too many times. I’ll never get those 90 minutes back.

The Overviewing Overview

The big keys you need to know about PRI if you haven’t already been reading my stuff.

  • We are asymmetrical in form and function.
  • Our respiratory and neurological lateralization drives us to being right-dominant individuals. We normally favor right-stance.
  • If we stay lateralized over time, it becomes much harder to break this pattern. We become neurologically rigid (credit the term to my boys Bill and Eric) and lose triplanar capacity to move.
  • The goal is to manage these asymmetries so we can establish alternating (what happens on one side the exact opposite occurs on the other) and reciprocal (a joint goes through the full range of motion in one plane) activity.

We achieve alternating reciprocal function through respiration. Breathing regulates and balances the nervous system, which PRI values as most important. Combined with knowledge of triplanar biomechanics, and we can see what PRI focuses on:

  • Respiration
  • Neurology
  • Biomechanics
Nate Dogg and Warren G had to alternate. Or regulate. Or whatever, keep reading!
Nate Dogg and Warren G had to alternate. Or regulate. Or whatever, keep reading!

What the Hell is a ZOA?

The ZOA, or zone of apposition, is the portion of the diaphragm that is directly adjacent to the inner aspect of the lower rib cage.

As we fully exhale via concentric abdominal activity, the ribs go down and in. We establish a ZOA. As we inhale, the abdominals eccentrically maintain a ZOA. The ZOA allows the diaphragm to stay domed and function maximally for respiration.

Comparing right and left diaphragms, the right diaphragm is better predisposed for many reasons to have a better ZOA than the left. This dominance via the right diaphragm’s large crura pulls the lumbar spine to the right.

The left diaphragm is shortened and better able to act as a postural muscle; pulling the spine into extension; becoming an agonist to the paraspinals.

Ergo, we want to do what is possible to establish a ZOA on the left. This piece is foundational for transitioning into left stance.

 Ok, so Right Diaphragm is King. What else Lateralizes Us?

The triangularis sterni/transverse thoracis is built to combat left chest wall hyperinflation. Its fibers on the left side extend up to the second rib, which is one rib higher than on the right. Since this muscle is a powerful exhaler, this asymmetry helps promote greater exhalation from the left chest wall.

 

It's science brah.
It’s science brah.

The other obvious asymmetry includes the lungs. The right lung has three lobes, and the left two. Aside from the right mediastinum containing less stuff, these lobes helps maximize alveolar air exchange when the pressure gradient is adequate for right chest wall airflow. The left chest wall easily pulls in air, so only two lobes are necessary for adequate oxygenation.

Neutral Neutral Neutral. You say that all the time. What’s that?

 Neutrality is a state of rest; a transitional zone.

Moving in and out of neutrality constitutes going from one end-range of motion into a transitional zone between the other end-range of motion.  This transitional zone is where neutrality lies.

When we are in a neutral state, our body stops moving and attempts to rest. We need this state so static activities (e.g. sitting, sleeping) are performed without excessive tone. Finding this resting point better allows us to move out of this state during dynamic activity.

Neutrality reduces our normal right lateralized bias and maximizes capacity to move in three planes bilaterally.

“Neutrality is not a point on a map. It’s a parasympathetic state of being.”  ~ James Anderson

Alternating and Reciprocal Stuff

 As stated above, alternating activity is when what occurs on one side the exact opposite occurs on the other; reciprocal activity is a joint going through full range of motion.

However, an interesting concept was presented at this course that I haven’t thought about. Just because one a joint is in one position on one side doesn’t mean the opposite must occur on the other side.

Take this example. Let’s say that I am in right stance. My trunk would normal rotate to the left. What happens if I need to see something occurring to right while I am on my right leg?

 

Like perhaps here.
Like perhaps here.

Obviously these situations do occur.  Therefore, alternating reciprocal activity constitutes that if I am on my right leg, my trunk could go right or left. I have options to have my body move in an ipsilateral or contralateral fashion.

Why Does Humeroglenoid (HG) Horizontal Abduction Test Thoracic Rotation, and Why does it Become Limited?

 In the right brachial chain (RBC) pattern, the thorax begins to rotate to the left via left rib external rotation and right rib internal rotation.  Due to this ribcage activity, the sternum is rotated to the right, and the left chest wall is hyperinflated.

Potential t-shirt? Tattoo?
Potential t-shirt? Tattoo?

The left pectoralis major is what would limit horizontal abduction in this case. The attachments for the pec include the sternum and the lateral lip of the bicipital groove. If the sternum rotates right, the pec elongates. The pec major is also an accessory inspiratory muscle, so it becomes neurologically active to attempt to draw air into the hyperinflated left chest wall.

Since the left abdominals are not in a position to create a ZOA, the pec is unopposed. Pec major tone limits horizontal abduction; thus signifying limited right thoracic rotation.

You Mean Someone Actually Talks about the Bilateral BC???

 There is a case in which both sides of the thorax become extended, hyperinflated, and ribs become externally rotated. This state is known as the bilateral brachial chain (BBC).

This positions leads to both hemidiaphragms functioning as postural stabilizers more so than respiratory muscles.

Trunk rotation would not occur on either side, thus horizontal abduction would be positive on both sides.

A New way to think of tests

 There were a couple seated tests that were introduced in this course, but one big key was talked about regarding all the PRI functional tests:

Do they feel the same on both sides?

Does your left feel like your right do? (read as though I said this through a talk box).
Do you, you, left feel like your right do? (read as though I said this through a talk box).

In other words, if a muscle contraction is to be felt during a portion of the test, is the contraction an equal intensity on both sides. If both sides are not equal, that may affect the way you decide to grade your tests.

How be Dem Feets of Yours?

 In the left AIC pattern, the left foot is in an everted and pronated position. Whereas the right foot is in a more inverted and supinated position.

If the right medial longitudinal arch and calcaneus do not have enough support, be it from tissue or footwear, the right arch and medial foot may collapse to reach the floor. This foot is not pronated however, but is pronating.

If the feet have gotten to the point in which this pattern cannot be overcome, supportive footwear may be indicated. The keys to a good shoe include:

  • Stable heel counter; both posteriorly and laterally.
  • Stable midfoot
  • Flexible forefoot.

This footwear allows for calcaneal frontal plane control and supports the medial longitudinal arch. The inherent forefoot flexibility supports gait propulsive forces.

Having good shoewear can better allow the patient/client to find and feel areas necessary for alternating and reciprocal activity.

Your Habits, They Kinda Sorta Matter

Look at your stove. Tell me which burner is your favorite.

 

Come clean.
Come clean.

Did you choose the bottom right burner? Why is that one usually the largest? It fits a pattern of right-handed dominance. A pattern of right lateralization. It’s normal.

James pointed out many different habitual things that could influence one’s position.  Think about where you like to be in some of these examples.

  • What side of the bed to do you sleep on? If you like the right, you’ll reinforce the Left AIC/Right BC. If you like the left, you are either neutral or patho.
  • What side of the couch do you nap on? The right side is usually preferred; especially if lying on the right side. If you like the left side of the couch and face out, you likely have a patho thorax.
  • Which island in your kitchen do you like? Assuming equal cupboard space, you probably prefer the island left of the stove compared to the right. Left island allows for right reach

There were many other examples that demonstrated the way our lives influence our patterned behavior. Making people become aware of these tendencies, and showing strategies to affect these preferences could be a way to help one integrate alternating reciprocal activity throughout the day. I can envision teaching someone to cook on their left burner as their HEP.

“Patterns develop into preferences.” ~ James Anderson

Random Lessons

  • Stretching doesn’t work because it doesn’t shut tone off. Tone is increased because stretch is a force that is thrown at the system. The system responds to this force by increasing tone.
  • Torsion = compression. Think the lower back.
  • In the Hruska Adduction lift test, the bottom leg is looking at stance phase, the top leg looks at swing phase of gait.
  • In the Hruska Abduction lift test, the top leg is in swing phase, the bottom leg is in stance phase.
  • When treating someone, go after the most limited snowball (sacrum, sternum, sphenoid).

Home Integration Exercises

James gave many examples of what exercises might be beneficial for different situations (bed mobility, transfers, gait, etc). There were several neat exercise variations he introduced. I’ll show you some of my favorites.

This first activity helps establish a ZOA while rotating the trunk to the right. An easy way to slowly expose a right lateralized system to the left.

A neat trick when sitting is to press the back of your leg into an object to get left hamstring.

Also really loved how flexing the hip isometrically into a table intensified everything in this left stance exercise.

James also gave us several little tips and tricks to help improve exercise performance:

  • Use several pillows to flex the patient and achieve a better ZOA.
  • Use toilet paper rolls to create isometric adduction.
  • Use paper towel rolls if one must move his or her hips during an activity; these roll better than toilet paper for example.
Apparently many uses
Apparently many uses

Da Verdict

 I can’t say one bad thing about this course. In fact I’d say I got more out of this course than I thought I would. This was the best overview of PRI that I have witnessed.

For newbies to PRI, you will get blasted with a lot of content, and it won’t be easy to digest the first time around. The manual is so well done though, that this course provides a great way to learn the most about PRI in the broad sense. You could most certainly start your PRI journey here.

For the vets, concepts will become better understood and you will get some great exercise variations.

So should you check out PRI Integration for the home?

Of course!!!!
Of course!!!!

Great James Quotes

  • “Recliners are the thing.”
  • “Geriatric clients are my favorite athletes.”
  • “Toilet paper rolls are neural integrators.”
  • “Treat patients how they feel inside.”
  • “That’s like influencing your mother.”
  • “The diaphragm is the core of your core.”
  • “The brain is amazing because it can adapt to anything.”
  • “All human beings are right-sided dominant in everything.
  • “If you are one step ahead of the crowd, you are a genius; if you are two steps ahead of the crowd you are a crackpot.”
  • “If you’re not domed, your toned.”
  • “People cannot rest themselves.”
  • “Do you know any stretch that says take 3 breaths, clap your hands, and smoke a cigarette that gives you 40 degrees of shoulder motion?”
  • [on PT school] “You are going to charge me this much and give me three sentences on breathing??!!? You should give me three months! You should be ashamed.”
  • “Don’t blog that.”
  • “If I have 45 degrees overall in a muu muu I’m good.”
  • “Nobody in that Medicare room knows anything about gait.”
  • “Rod Stewart was dancing? He’s probably on amphetamines but good for him!”
  • “We’ve got a before collapse party and an after collapse party and the minimalist shoe wear goes to the after collapse party.”
  • “Whoa! PRI does nothing.”
  • “The left pelvis is different from the right. Drink!”
  • “Just blow the dang balloon up.”
  • “Recliners shut off people.”
  • “In a grandma course, really?”
  • “Don’t shift if shifting is irrelevant. Reach.”
  • “The diaphragm is your prime mover of the spine.”
  • “Don’t train not sure.”
  • “There is no problem with the pattern. The problem is when you can’t flip the coin.”
  • “The Timed Up and Go Test aka the hurry up and fall test.”
Some of my favorite crackpots.
Some of my favorite crackpots.

Course Notes: Dermoneuromodulation

What? You Mean You Have to Touch Someone???!!?!?

My gluttony for punishment continues. This time, I had the pleasure of learning Diane Jacobs’ manual therapy approach called Dermoneuromodulation (DNM).

My travels took me to Entropy Physiotherapy and Wellness in the Windy City. These folks were arguably the best course hosts I have ever had. We had lunch!!!! Both days!!!!! That is unheard of, so a big thanks to Sandy and Sarah for putting the course together.

I took DNM out of curiosity. I have been lurking around Somasimple on and off for the past couple years, and wanted to learn more about the methods championed there.

Believe it or not, I have yet to take a pure manual therapy course, DNM seemed like a great way to get my hands dirty. That darn PRI has lessened the hand representation in my somatosensory homunculus!

 

The representation shrinks by the day.
What my homunculus actually looks like.

One reason I haven’t taken a manual course is due to the explanatory models many classes are presenting. It seems as though few are approaching things with a neurological mindset, but I was pleased to hear Diane’s model. It is the best explanation I have heard yet.

I know that I usually list my favorite quotes at the end of the blog, but I wanted to share the best quote of the weekend right off the bat:

“I don’t know why.”

I heard this phrase so much throughout the course and it was quite refreshing. Diane made few claims about her technique, admitted who she “stole” from, and embraced the uncertainty that goes along with how her technique works.

Diane didn’t advertise her method as the end-all-be-all, and encouraged all of us to make up techniques of our own. She is just offering a non-painful sensory input that works quickly.

I wish more courses were this way.

Let us now press onward to a fantastic explanation for manual therapy.

 

Well done Diane, well done.
Well done Diane, well done.

Manual Therapy – An Interaction Between Two Nervous Systems

Diane started off with manual therapy’s theoretical basis. Manual therapy works predominately through your nervous system. We are made up of a brain, spinal cord, and nerves that extend from the cord.

The brain can be simply broken up into two components: the human brain and critter brain. The human brain sits our higher activity centers, and the critter brain runs the processes that keep us alive.

Under threat, the critter brain is going to do everything in its power to keep us alive, and this change can involve the protective mechanisms that go along with pain.

Aka Kevin Costner circa 1992.
Aka Kevin Costner circa 1992.

The critter brain carries out its processes through the body’s nerves. Nerves in the body tell the brain what’s going on, and the brain then tells nerves how to respond.

In order to calm our critter brain down, the clinician can communicate with the nervous system through cutaneous nerves. Our goal with our interventions is to touch the patient without hurting them. Hurt could irritate the critter brain. Instead, we want an enjoyable context for touch.

Kinda like Kevin Costner....circa 1992.
Also like Kevin Costner, circa 1992…minus the sexual implications

The patient’s role…Wait, what???!!!

Yes, the patient’s role in the manual therapy process is to guide the clinician to what feels best. It is this interactive and interoceptive model that helps reduce threat perception.  This context allows for the patient to be a little more in control of the manual therapy process.

It Rubs the Lotion on Its Skin

The skin is a pretty cool organ that can hold 20% of our blood supply and maintain temperature homeostasis. It has both peripheral (PNS) and central (CNS) nervous system influences. The PNS automatically activates to maintain skin temperature and the CNS can express itself through the skin. Those times in which you are embarrassed or scared reflect CNS status through your skin.

Due to the skin’s high innervation and vascularity, anytime we touch the skin we affect the neurovascular array. This change occurs through facilitating mechanoreceptors and physically altering cutaneous rami position.  The nervous system then evaluates this information to determine if the touch is a threat or not.

Tissue information is received through receptors. There are tons of them, but we have  a few major players:

Dermal receptors

  • Rapidly adapting mechanoreceptors – Turns on and shuts off by itself
  • Thermoreceptors – Responds to temperature change for duration of stimulus.
  • Nociceptors – Responds for stimulus duration. Can be set off by going perpendicular on skin.
  • Pacinian corpuscles – Turns on with stimulus onset and removal. Will continuously fire if stimulus fluctuates.
  • Meissner’s corpuscle – Turns on with stimulus onset and removal
  • Ruffini endings – respond to lateral skin stretch and are non-nociceptive. Slow adaptors to stimulus. Can fool the brain to alter muscle tone with skin stretch.

Epidermal receptors

  • Merkel cells – slow adapting to stimulus.

 

There is just a lot of stuff here.
There is just a lot of stuff here.

All the above receptors respond to stimuli and communicate information to the brain along sensory nerves. It turns out sensory nerves are incredibly long. Many of these nerves go directly from the skin to the brain. One cell! Anytime you touch the skin you are touching a direct extension of the brain.

Sensory input travels via the mechanoreceptors through the dorsal columns and spinothalamic tract in the spinal cord. Interestingly enough, the spinothalamic tract does not only carry nociception, temperature, and crude touch. Pleasant touch can also travel along this pathway.

The Dorsal columns input goes to the thalamus, which sends information to the somatosensory cortex. The spinothalamic tract goes to the thalamus first as well, followed by the somatosensory cortex, anterior cingulate cortex, and the insular cortex. These three areas are what Diane noted as “threat evaluation areas.” These areas are part of your critter brain.

Once the brain receives this information, it essentially talks to itself to determine if this information is important or not. If important, an output occurs to respond to the input.

 

We've all done it.

Many brain areas are a part of this conversation. The following locations contribute to the desired output in a particular way:

  • Limbic system – emotional experience.
  • Venteromedial cortex – pleasure, reward, meaning, creates positive reinforcement
  • Anterior cingulate cortex – bridge between instinct and rational; makes us worry about pain.
  • Orbitofrontal cortex – defers, suppresses, differentiates touch, interprets emotions (if you are in a bad mood, this is how your patient will know it…so be happy!).
  • Dorsolateral prefrontal cortex – Chooses behavior. This area is where therapeutic neuroscience education targets.

Explain Hyperalgesia

Pain is one possible output in response to various inputs. If pain is the desired output, changes can occur to increase sensitivity.

One possibility is hyperalgesia, in which noxious stimuli becomes extra sensitive.  Hyperalgesia can be primary or secondary.

To understand the two, we should first look at a sensory neuron.

Oooooooh....Ahhhhhhh.
Oooooooh….Ahhhhhhh.

A sensory neuron has two ends. The end that connects to the tissue is the terminal pole, and the end that travels to the spinal cord is the central pole.

Primary hyperalgesia affects the terminal pole.  Substances released by injured tissue activate nociceptors at this pole, creating the information cascade sent to the brain described previously.  We also know this as inflammation.

As the inflammatory process progresses, nociceptors send substances out to the tissues to promote enhanced firing. This change creates peripheral sensitivity, and is normal.

Secondary hyperalgesia (aka central sensitivity) has more fun at the central pole. TRPv1 is a receptor at the central pole that increases spinal cord and blood-brain barrier permeability, which allows for more nociceptive transmission to be received. Serotonin can descend from the brain to the spinal cord and sensitize these receptors as well.

Other changes that occur in secondary hyperalgesia include glial and satellite cells lowering the threshold at which nociceptors fire. The name of the game is to increase the nociceptive information coming in.

Both of these algesic mechanisms can simultaneously occur to protect a potentially compromised area. However, pain may not necessarily be experienced. Nociception involves threat detection, whereas pain involves threat perception. The two are not equal entities.

“The labeling of nociceptors as pain fibres was not an admirable simplification but an unfortunate trivialization.” ~Patrick Wall

Nerves n’ Stuff

The neurovascular bundle is connected via regional feeder vessels. These vessels ought to slide and glide with the nerves so blood supply is maintained. Movement is what keeps this system healthy.

Red - artery; Yellow - Nerve; Blue - vein; entire pic - Amazing
Red – artery; Yellow – Nerve; Blue – vein; entire pic – Amazing

These connections are vulnerable and can become sensitive to mechanical deformation.  Too much or not enough movement can decrease the nerve’s oxygen and glucose supply. A nerve will let you know if it does not get fed.

And if you listen quietly, the nerves will actually say that.
And if you listen quietly, you can hear the nerves saying that.

Deformation could translate into neuropathic pain, which is defined as pain caused by a lesion or disease in the somatosensory system. Neuropathic pain is not a diagnosis, but a descriptor.

The way one could determine if neuropathic pain contributes to one’s complaint is done quite algorithmically.  The following must be present:

  • Leading complaint must be pain.
  • Pain distribution must be neuroanatomically plausible.
  • History should suggest relevant lesion or disease.
  • Negative or positive sensory signs contained to lesioned area in question.
  • Diagnostic testing confirming lesion or disease explaining neuropathic pain.

The fewer of these criteria positive, the less chance there is of having neuropathic pain.

Theory into Therapy

Diane stressed that a therapeutic context must be established before implementing a manual intervention. This foundation occurs via a 4-step process

  1. Listen – Allows the patient to map you in their story. Your listening models how they listen to themselves.
  2. Interact  – Explain pain. This part will plant seeds to regulate future stressors.
  3. Treat – Provide non-nociceptive therapy, making sure to give the patient locus of control.
  4. Wait – Do not correct; wait for physiology to change and the desired output to emerge.

Wait-For-It

The object is to create the largest amount of descending modulation possible. We therefore mobilize the cutaneous nerves via “yesiceptive” contact and interaction.

DNM 101

Though Diane does not believe in trigger points, she does believe in sore spots that often have a different feel about them. Our goal is to change these sore spots without worsening them.

Cutaneous nerves anastomose in various ways, so everyone’s anatomy is going to be slightly different. Thus, there can be no precision or specificity with treatment. We just have to somehow move nerves in a fashion that results in reduced pain.

The assessment process was my one gripe with the course. Each technique was given clinical situations that they may work with. We then assessed with active movement followed by palpating tender spots. However, these spots can be present on many people even if pain is relieved, are unreliable to assess, and do not always contribute to the patient’s complaint. How can we say that performing this intervention is the right thing to do for this patient?

Well Diane freely admitted palpation’s unreliability, she has also been practicing long enough that she has the pattern recognition to know when techniques ought to be implemented. Novice clinicians likely lack this skill. There must be some way to provide an assessment that may lead you to performing one mobilization compared to another.

I espouse Charlie Weingroff’s principle of “can your treatment beat my tests.” Since I am a PRI enthusiast, I used those objective measures to test treatment efficacy. When implemented thoughtfully, DNM can change PRI objective measures fairly quickly and in a pain-free manner.

Zac = sold on both counts.

DNM is actually fairly simple to perform. The technique is a combination of positional release with skin stretch; fine-tuning performed throughout to maximize treatment effect.

Diane gave us many techniques that seem to work over specific areas, but really you can stretch skin in any fashion. Here are some examples of the basic techniques utilized in the course.

Longitudinal distraction – Nerves move up.

Shearing distraction – Nerves are lifted and twisted.

Unloading – Nerves move up.

Contralateral unloading (the balloon) – Go to the opposite side of the sore spot.

Rotational shearing

Circumferential unloading

 Once these techniques are implemented and symptoms change; exercise ought be to given to reinforce the changes. Though no specifics were given, Diane suggested ideas of using positioning strategies, taping, self-DNM, etc. Her objective was to give us the manual technique, then supplement with our exercise strategies of choice.

Verdict

Overall I really enjoyed Diane’s course. She has given the best manual therapy theoretical explanation I have heard, and the technique is very gentle and effective.  She can beat my tests. I think that if these maneuvers are implemented into a sound assessment, you can add a very powerful sensory input to your repertoire.

Verdict: Do it. The neuroscience alone is worth the price of admission.

Manual therapy will be yours, do as you please!
Manual therapy will be yours, do as you please!

Fun Facts

  • Nerves slide and glide like a telescope.
  • A rete is a dense convoluted birds nest of cutaneous nerves over a bony prominence. These are over most every bony prominence.

Dianetics (See what I did there??)

  • “We belong to our brain more than our brain belongs to us.”
  • “We’re not treating anatomy, we’re treating physiology.”
  • “Spinal cords have not got much smarter since fish days.”
  • “You can’t trust the brain pretty well. It makes up stories.”
  • “It’s never a good idea to treat someone who is feeling better than you are.”
  • “Therapeutic neuroscience education is accurate and relevant pain information.”
  • “Pain is physiological.”
  • “You are only as old as your C-fibers.”
  • “It probably serves us well to not believe everything our brain tells us. “
  • “Pain is the story built from all inputs.”
  • “Pain descriptors are more of a way for the patient to export their feelings.”
  • “Having a license to touch people is an enormous privilege.”
  • “I can’t think of a better thing then using human brains to help other brains.”
  • “The less you do the better results you are going to get.”
  • “I have to tell you up front. I am a trigger point atheist.”
  • “Evolution is weird, and it’s not that smart actually.”
  • “When I don’t have a monitoring hand I’ll use my head to push the skin on the butt. I call it the head butt technique.”
  • “There will be asymmetric positions people adopt. It’s their comfort position.”
  • “We’re asymmetric in our behavior.”
  • “We’re not going to deal with your ovary by the way.”
  • “Those who have IT band syndrome, I don’t even know what that means.”
  • “I found this on the internet so it must be true.”
  • “The pelvic floor holds up a bunch of stuff. And you don’t know what you’ve got ‘til its gone.”
  • “Heels just love to be cranked on.”
  • “Let your brain be creative when you treat.”
  • “It’s [DNM] soft and easy so you can die comfortably at your job.”
DNM is soft and easy, no matter what your job is.
DNM is soft and easy, no matter what your job is.

PRI and Pain Science: Yes You Can Do It

Questions

You may have noticed that my blogging frequency has been a little slower than the usual, and I would like to apologize for that. I am in the midst of creating my first course that I am presenting to my coworkers. It has been a very exciting yet time-consuming process. It makes me excited and more motivated to someday start teaching more on the reg.

Ever since I started blogging people started asking me questions. These range from many topics regarding physical therapy, career advice, and the like. Some of the more frequent ones include:

  1. What courses should I look at?
  2. Any advice for a new grad?
  3. Seriously, Bane. What’s the deal?
Some questions are best left unanswered.
Some questions are best left unanswered brother.

But the one I get asked more often then not is as follows:

“Zac, how do you integrate PRI into a pain science model?”

A great question indeed, especially to those who are relatively unfamiliar with PRI. With all the HG, GH, AF, FA, and FU’s, it’s easy to get lost in the anatomical explanations.

Hell, the company even has the word (gasp) “posture” in the title. Surely they cannot think that posture and pain are correlated.

One of my favorite actors of all time. RIP
One of my favorite actors of all time. RIP

I think there is a lot of misinformation regarding PRI’s methodology and framework. What needs to be understood is that PRI is a systematic, biopsychosocial approach that predominately (though not exclusively) deals with the autonomic nervous system. The ANS is very much linked into pain states, though not a causative factor.

But of course, that may not be enough. Perhaps we can dig a little deeper into what may be going on. My hope with this blog is to make a guide to integrating two very effective paradigms which I feel are not mutually exclusive.

PRI Patterns and Nociception

 David Butler discusses many nociceptive processes, including mechanically-induced pain, inflammation, and ischemia.

I feel that the PRI patterns, albeit normal, could contribute to nociceptive processes. Mechanical pain makes the most sense. We could think of this process as typical anatomy/biomechanics. If one is in a right-lateralized and extended position, certain areas are going to be more prone to mechanical deformation than others.

Inflammatory processes could be caused by acute injuries secondary to position. The easiest example I could give would be an ankle sprain. If someone is in a right lateralized pattern (a la Left AIC), the right ankle/foot complex would be more supinated, thus being more at risk to sustain an ankle sprain. So in these cases, a right lateralized pattern could be one of many risk factors for leading to an injury.

Ischemic nociception is where things get interesting. There are two ischemic features that Butler mentions in “The Sensitive Nervous System” that stood out to me:

  1. Symptoms after prolonged or unusual postures.
  2. Rapid ease of symptoms after a change of posture.

If I am right lateralized and unable to leave right stance, this position could become ischemic after a prolonged period. Less movement, less axoplamsic activity, less blood flow.

You can't feel the flow when you can't move.
You can’t feel the flow when you can’t move.

Moreover, symptoms would be much more challenging to relieve. If I am unable to adduct and internally rotate my hip maximally, then I effectively limit what movement planes I am capable of utilizing. This concept is what Bill Hartman calls movement variability. When a position becomes nociceptive, movement must occur to reduce danger signals and restore axoplasmic and blood flow. I am looking for freedom. But triplanar activity is unachievable, movement freedom becomes a limited resource.

I simply lose the ability to change posture, which limits my ability to relieve ischemia.

 PRI Patterns and Peripheral Neuropathic Pain

 When I am in right or left stance, the nervous system slides and glides to accommodate position. Suppose I am in right stance. Right stance would require my right hip to be more extended, adducted, and internally rotated. My left hip would be flexed, abducted, and externally rotated.

When my hips are positioned as above, the sciatic nerve would be more taut on the right and slacked on the left. Now if I never leave right stance (aka left AIC), then I could potentially be more at risk for tension impairments on the right.

Another example would involve spinal position. Research demonstrates that humans have a naturally right oriented spine (here & here) which is precisely what PRI advocates. This orientation may bias more compression on the right nerve root than the left. If we have someone who presents with a dominant PEC i.e. spinal hyperextension, we could potentially see increased compression bilaterally.

Here we go yo, it's just a potential scenario.
Here we go yo, it’s just a potential scenario.

PRI, What a Great Defense

Now of course, we know very well that nociception and peripheral neuropathic issues are neither necessary nor sufficient for a pain experience. So how does PRI relate to pain?

Simple, the PRI patterns are the perfect protective postures for us to assume when we are threatened.

We drive these patterns via our autonomic nervous system. If you read Stephen Porges work, he discusses the concept of neuroception. Neuroception is how our nervous system’s evaluates risk. We take all sensory information in regarding our environment and determine if we should fight, flight, freeze, or relax and socialize.

When we neurocept (is that a word??) something as a threat, we will become more sympathetically driven and likely use our most efficient processes to respond to the threat. We use what we know.

Play Scrabble with me and you'll find I make up words all the time.
Play Scrabble with me and you’ll find I make up words all the time.

We bias ourselves to the right because motor planning occurs in the left hemisphere regardless of hand-dominance. If I stand on my right leg, I simply am better able to make my next move than if I were to stand on my left.

We will increase activity of our anti-gravity muscles, our extensors. To defend against a threat, it probably makes sense to stay upright. This function has governors present in the reticular formation. The pontine reticulospinal tract controls extensor tone, and the medullary reticulospinal tract inhibits this tone. One of these is spontaneously active and the other is not. Guess which one? Extension is the norm to keep upright. Thus, extensor tone is the brain’s reflex-driven path of least resistance. Perhaps if I am under threat long enough, I become a PEC?

Breathing will become faster and shallower. Take a look at the diaphragm. Which side is larger?

Would you look at that.
Would you look at that.

The right hemidiaphragm is larger and more powerful than the left. If I am already biased to the right and have a stronger muscle on the right, breathing becomes a less conscious process.

My point of listing these plausible changes in response to theat is to demonstrate that we are fairly similar creatures. Bill again, helped me realize this on a post he made at Somasimple.

If a lion were to walk in the room, what physiological changes would we undergo? Our heart rate would increase, pupils would dilate, HRV decreases, we sweat, etc. Are these responses not the same for all humans? These physiological changes are a common human pattern. Could it be possible there is a common threat response in postural and muscular activity as well? This pattern of positioning and neurological bias is what I feel PRI has put together more completely than anyone else.

Granted, we can still account for individual differences, but realize these changes are likely minor variations off the normal response.

When under threat, your heart rate increases 20 beats per minute, mine increases 10.

When under threat, your sweat accumulates on your brow, mine on my palms.

When under threat, your left anterior hip capsule becomes lax via compensatory external rotation, mine stays intact after compensatory external rotation.

Similar responses occur through varying degrees.

We're not so different, you and I.
We’re not so different, you and I.

Treating Pain Through PRI Approaches

I think PRI can influence the pain experience by altering autonomics via the vagus nerve. Paced breathing can positively influence pain states, and PRI breathing-style is very much paced.

The positions utilized are the farthest removed from the typical protective response when we perceive threat. If right stance with increased extension is what we do when we are threatened, then I am going to get you into left stance and flex you until the cows come home.

PRI essentially is graded exposure into left stance and parasympathetic paradise.

That doesn’t mean that PRI is going to eliminate the entire pain experience in all cases. There are some people who have injuries that are producing nociception, and may take time to heal. There are some people who have enough neural sensitivity requiring a hands-on or neurodynamic approach. There are some people who have centrally-maintained pain experience that requires graded exposure, pacing, and homuncular refreshments. The autonomic protective response is one piece of the puzzle, and altering that piece is the only way one can know if it is contributing to one’s complaint.

Therapeutic Neuroscience Education…PRI Style

So usually when I educate patients I just run through the above as quickly as possible…

download (2)

Okay that’s not 100% true.

I actually use the concept of a home security system to explain how PRI patterns are a part of the pain experience. Go ahead, watch the video, I’ll wait.

So as you can see, I do not go into nitty gritty detail of PRI methodology. It is mostly not necessary and could potentially increase threat perception. But framing the system as done above can help the patient understand why we may work at areas far away from the pain experience. We are treating what area of the system continues driving the protective response. We are treating the person.

In Summation

PRI is a very powerful system that does not have to go against current pain research, not that it ever did. But the above may be a potential framework and justification as to how PRI affects the pain experience.  It is the framework that I operate on, and will continue operating on until I am shown otherwise.

I hope that I am.

Who knows where the rabbit hole goes next.
Who knows where the rabbit hole goes next.

The Post Wonderful Time of the Year: Top Posts of 2013

The Best…Around

Time is fun when you are having flies. It seems like just yesterday that I started up this blog, and I am excited and humbled by the response I have gotten.

Hearing praise from my audience keeps me hungry to learn and educate more.

I am always curious to see which pages you enjoyed, and which were not so enjoyable; as it helps me tailor my writing a little bit more.

And I’d have to say, I have a bunch of readers who like the nervous system 🙂

Like porn for my readers.
Yeah, it’s pretty cool

I am not sure what the next year will bring in terms of content, as I think the first year anyone starts a blog it is more about the writing process and finding your voice.

Regardless of what is written, I hope to spread information that I think will benefit those of you who read my stuff. The more I can help you, the better off all our patients and clients will be.

So without further ado, let’s review which posts were the top dogs for this year (and some of my favorite pics of course).

10.  Lessons from a Student: The Interaction

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Actually, I have found I now have more success setting up my interactions like this.

This was probably one of my favorite posts to write this year, as I think this area is sooooooo underdiscussed. Expect to be hearing more on patient interaction from me in the future.

9) Clinical Neurodynamics Chapter 1: General Neurodynamics

Any post with Predator in it has been shown to increase T levels by 300%
Any post with Predator in it has been shown to increase T levels by 300%

Shacklock was an excellent technical read. In this post we lay out some nervous system basics, and why we call neurodynamics what we call it.

8) Course Notes: Graded Motor Imagery

Drawing skillz unparalleled.
Drawing skillz unparalleled.

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.

7) Explain Pain Section 6: Management Essentials

I totally recall how awesome this post was...Just see the movie
I totally recall how awesome this post was…Just see the movie

Hopefully after following this blog you have a better understanding of pain than the average bear, so here are some basic ways we can manage the pain experience.

6) The Sensitive Nervous System Chapter III: Pain Mechanisms and Peripheral Sensitivity

When I see someone stub their toe, I'm not thinking a stubbed toe.
When I see someone stub their toe, I’m not thinking a stubbed toe.

One of my very first posts, so maybe a Cupples classic?

Anyway, here we explore in great detail what nociception and peripheral neuropathic pain are; and why you should go to the emergency room when you stub your toe 🙂

5) Course Notes: PRI Myokinematic Restoration

Because why not?
Because why not?

I am very glad this post got many views, as I feel the message these guys send is some of the best on the market. Here is PRI 101, and expect to hear a lot more about their work this upcoming year.

4) The Sensitive Nervous System Chapter VIII: Palpation and Orientation of the Peripheral Nervous System

There was a time in which I didn't post funny pics...Besides, who doesn't like Led Zeppelin?
There was a time in which I didn’t post funny pics…Besides, who doesn’t like Led Zeppelin?

One underrated way to assess the nervous system is via palpation. You can get a lot of interesting responses on people. Here we learn how.

3) Clinical Neurodynamics Chapter 2: Specific Neurodynamics

I really feel like my artistic endeavors became their own once I started drawing in color.
I really feel like my artistic endeavors became their own once I started drawing in color.

In this post we learn a lot of local nervous system tidbits, and more information on my future Therapeutic Microsoft Paint Course 🙂

2) Course Notes: Mobilisation of the Nervous System

That my writing pace has slowed down.
That my writing pace has slowed down.

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.

1) Explain Pain Section 1: Intro to Pain

Because what's a post on my site without a Bane reference?
Because what’s a post on my site without a Bane reference?

This section could be a manifesto for this blog. Learning and understanding pain has been one of the biggest game changers for me as a clinician and writer.

Simply put, if you work with people in pain, this section is a must-read.

C’est Fini

So there you have it. Which posts were your favorite? Which would you like to see more/less of? Comment below and let a brother know.

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Advanced Integration: Day 2 (Triplanar Activity)

For day 2 we discuss more and more the areas that help support ZOA establishment. Read on comrades.

For day 1, click here

Neutral

Neutral can be described as a position in which certain muscles are disengaged; those that make up chains in the human system (i.e. left AIC, Right BC, right TMCC). It is neutrality that allows us to function out of an unbiased non-lateralized position.

We will never be fully symmetrical because we are neither built as such nor function cortically as such. But being able to be as symmetrical as possible may allow our bodies to function favorably.

Achieving neutrality is only step one in the process. It allows for someone to accept triplanar movement. Once one can reach neutral, then you may teach them how to move with the left and right sides of the body.

Is it possible to be too neutral? The answer is it depends. Mike Cantrell, one of PRI’s instructors, discussed a sprinter he was treating. Mike was able to get him neutral, but once this occurred his times worsened. This result goes back to part 1’s discussion regarding variability. In this case, being neutral, being too parasympathetic, made him slower. We could akin this to almost parasympathetic overtraining.

The crazy thing? This sprinter’s sister had died earlier in a week he was scheduled to see Mike. The guy came in as neutral as could be. His nervous system shifted him towards this state as a way to disengage, thus leading him to difficulty reengaging the requisite sympathetic tone needed for sprinting.

As we can see, there are multiple influences present that can affect one’s body position. Whatever inputs that your nervous system receives will influence system outputs. It could be nociception from a facet, your foot contacting the ground, an altered visual system…

“Or maybe, maybe, maybe, you need a new wife” ~Ron Hruska

PEC-Speak

We talked a little bit about PEC-patterns, which Ron likes to now call bilaterals. This nomenclature means that both sides are relatively symmetrical positionally. When talking about these individuals, much discussion revolves around the pelvic inlet and outlet. But I will save that talk for next month once I attend pelvis 🙂

We also discussed a little bit more regarding the nebulous Hruska adduction lift test with this clientele. And basically, someone who presents with a PEC pattern may not be able to truly alternate until they score 2/5 (bottom-leg can internally rotate) on either side. Any score lower and the low back will likely compensate.

We are Some Families

We spent a great deal of the day discussing the different planar PRI families, which when combined beautifully illustrate the systematic approach this organization utilizes. Here are the families that we go after in order:

  1. Sagittal plane (stoplight – help turn off chains): left hamstring, right iliacus, right lower trapezius/tricep, right rectus capitis posterior and obliquus capitis superior, right rectus femoris and sartorius
  2. Frontal plane adduction (the organizer – puts us into the opposing chain): Left IC adductor, right psoas major/minor, right serratus anterior, left iliacus
  3. Frontal plane abduction (the strength builder): right obturator internus & externus, right abductor/glute med, right upper trapezius, right rectus capitis lateralis, right SCM, left obturator internus and iliococcygeus
  4. Transverse plane (Does the work): Right pec major, left pleura, right glute max, left middle trap, right rectus capitis posterior major, Right obliquus capitis inferior and superior, Left lateral pterygoid, Left SCM, left gluteus medius
  5. Internal rotation (closes the deal to triplanar function): anterior left glute med, left iliacus, right subscapularis, left serratus anterior, left anterior temporalis, left lateral pterygoid, posterior right glute max, right piriformis, coccygeus, and inferior glute max.
  6. Integration (opposition maintainers):  Left transversus thoracis, left abdominals

So the activities that we learn in the basic courses are really just taking pieces of these families to progress movement. These activities are well and good no doubt, but ultimately we want to utilize as many of these muscles as possible.

Take the sagittal plane for example. In the Myokinematic Restoration course we learned specific activities to turn on the left hamstring. Here we only have one sensory input in the family helping us achieve our goal. In more advanced courses, we would perform activities that incorporate many, if not all the muscles in the sagittal family. Progressing in this fashion significantly increases the amount of sagittal input that the brain receives. Summating this input may compel the brain to respond in some way, hopefully quieting down overactive muscle chains and facilitating triplanar movement.

(In)Famous Ron Quotes

  • “You can’t stand on both feet. If you could you’d be a corpse.”
  • “Do you want GERD? Do I want GERD? I don’t want that.”
  • “I kinda think Lady Gaga is cool sometimes. I dressed up.”
  • “Physiological is psychological.”
  • “It is impossible to have a neutral spine. It’s constantly in fluctuation.”
  • “Everything you bring to your body is either used or expelled.”
  • “Every time I see a high heel I worry about their enamel.”
  • “They’re [people in high heels] oral butt clenchers.”
  • “Abduction is Lady Gaga.”

Cantrellisms

  • “If we can make you worse, we can make you better.”
  • I won’t put some of his famous similes, namely because I can’t remember the context and may steal some of his magic 🙂
He was born that way...But he wasn't born that way.
He was born that way…But he wasn’t born that way.