Just when I thought I was out, the clinic pulls me back in.
Though I’m glad to be back. There’s just a different vibe, different pace, and ever-constant variety of challenges that being in the clinic simply provides. This has been especially true working in a rural area. You see a much wider variety, which challenges you to broaden your skillset.
Previously, I was all about getting people in and out of the door as quickly as possible; and with very few visits. I would cut them down to once a week or every other week damn-near immediately, and try to hit that three to five visit sweet spot.
This strategy no doubt worked, and people got better, but I had noticed I’d get repeat customers. Maybe it wasn’t the area that was initially hurting them, but they still were having trouble creep up. Or maybe it was the same pain, just taking much more activity to elicit the sensation.
It became clear that I was skipping steps to try and get my visit number low, when in reality I was doing a disservice to my patients. This was the equivalent of fast food PT—give them the protein, carbohydrates, and fats, forget about the vitamins and minerals.
Was getting someone out the door in 3 visits for me or for them? The younger, big ass ego me, wanted to known as the guy who got people better faster than everyone else. Yet the pursuit became detrimental to the patient’s best interest. There were so many other ways I could impact a patient’s overall health that I simply sacrificed in place of speed.
I only got them to survive without pushing them to thrive.
I see a lot of individuals proudly proclaim how many visits it takes for them to get someone out of pain, but pain relief is only part of the equation. There are so many more qualities we can address before we consider a rehab program a success.
This stark realization has reconceptualized how I structure a weekly rehab program. I now emphasize all qualities necessary to return to whatever task the patient desires, and attempt to inspire them beyond those initial goals.
You want to know what my visit average is right now?
I stopped counting, and started treating.
Let’s look designing the rehab week to take your clients to the next level.
You shed that mindset with the game on the line. You must do all in your power to get that player back on the court tonight, expediting the return process to the nth degree.
I had a problem.
Figuring out the most efficient way to treat an ankle sprain was needed to help our team succeed. I searched the literature, therapeutic outskirts, and tinkered in order to devise an effective protocol.
The result? We had 12 ankle sprains this past season. After performing the protocol, eight were able to return and finish out the game. Out of the remaining four, three returned to full play in two days. The last guy? He was released two days after his last game.
It’s a tough business.
The best part was we had no re-sprains. An impressive feat considering the 80% recurrence rate¹. Caveats aside, treating acute injuries with an aggressive mindset can be immensely effective.
Back in April I had the pleasure of finally attending PRI’s annual symposium, and what an excellent learning experience.
The theme this year was working with high-powered, extension-driven individuals.
The amount of interdisciplinary overlap in each presentation made for a seamless symposium. Common themes included the brain, stress response, HRV, resilience, and drive. These are things altered in individuals who are highly successful, but may come at a cost to body systems.
If you work with business owners, CEOs, high-level athletes and coaches, high level positions, straight-A students, special forces, and supermoms, this symposium was for you.
And let’s face it; we are both in this category!
There were so many pearls in each presentation that I wish I could write, but let’s view the course a-ha’s.
The Wise Words of Ron
Ron Hruska gave four excellent talks at this symposium regarding high performers and occlusion. Let’s dive into the master’s mind.
People, PRI does not think extension is bad. Extension is a gift that drives us to excel. Individuals who have high self-efficacy must often “over-extend” themselves. This drive often requires system extension.
Extension is a consequence, and probably a necessary adaptation, of success.
If this drive must be reduced to increase function and/or alter symptoms in these individuals, we have to turn down the volume knob.
How can we power down these individuals?
Limit alternate choices – These folks take a wide view of a task
Set boundaries – These folks attribute failure to external factors
Making initial tasks successful – So these folks don’t give up at early failures
Objectively measure improvement – This helps motivate people to continue
Establish rhythmic activity that reflects specific set goals – the higher the goals the more likely the positive change.
A Tale of Two Forward Heads
We discussed a lot of attaining neutrality at the OA joint. What does that entail?
A: Both occipital condyles centered in the atlas fossa with unrestricted lateral flexion.
What is needed to have that?
55-60 degrees of cervical extension.
Equal bilateral first rib rotation position.
Centric occlusion with the anterior teeth guiding protrusive movement and canines guiding lateral movement.
Normal maxillary and mandibular teeth contact.
Ability to nasal breathe.
Alternating pelvic capability.
Normal hearing bilaterally.
Lose any one of these and a forward head posture may occur.
The two types of FHP we see include one with the atlas migrating forward with increased cervical flexion and occipital protraction.
And one in which the atlas migrates backward on the occiput in which excessive upper cervical flexion coupled with lower cervical/upper thoracic hyperextension.
With the former’s case, these individuals have a harder time feeling posterior teeth; a loss of frontal plane. When one loses frontal plane, the individual must attempt to increase anterior guidance via extension. Strategies used to do this include tongue thrusting, bruxism, fingernail biting, mouth breathing, clenching, etc. These strategies are protective in nature as they limit potential stress at the TMJ and OA.
Most of the latter include your bilaterally extended individuals. They retrude the atlas to significantly increase cervical stability. This hyperstability allows for dominant performance in the sagittal plane. These individuals may need more visual interventions.
She’s a Wise Woman
Dr. Heidi Wise gave one of my favorite presentations of the symposium. She discussed vision’s role in extension-driven individuals.
Vision is the most dominant sensory modality, as it has the ability to override all other senses to redirect attention. To me, this is why vision is such a powerful way to get someone neutral.
Redirection of attention through the visual system occurs through saccades. These eye movements occur 85% of the time our eyes are being used. This is how the visual system detects a salient stimulus.
If visual processes hold someone in an extension pattern, it may become extremely difficult to near-impossible to overcome.
Here is how we start thinking a visual process may be promoting an extension pattern:
Those who cannot inhibit extension with traditional floor-up activity.
Late-onset (past puberty) or severe near-sightedness.
People with extremely good eyesight.
Folks who over-focus on objects straight ahead (people who stare).
People who walk with purpose (makes me think of my mom in the mall!).
If someone over focuses (read: nearsighted), eye exploration is minimized. It becomes much harder to notice change, or salience. This is how the visual system can keep someone stuck in a stress response.
What is needed to see close?
Increases in acetylcholine and norepinephrine.
Reflexive increase in neck/head muscle tension. More so if one must strain to see.
Do this too long, and we can see unfavorable autonomic, visual, and neuromuscular stress.
And guess what visual field research is showing we better attune to? The right side; more specifically, the right upper visual field.
The PRI goal? We want to restore ambient vision in these individuals to process three planes of visual motion.
Here were some of Heidi’s recommendations for how to do so.
Take breaks from a task to move.
Be aware of surroundings on both sides without looking when walking.
Walk slower than usual.
Look around using your eyes independent of your head.
If nearsighted, take glasses off occasionally and “be OK” with things far away being blurry. Don’t strain to see well.
Have top of computer screens at about eye level. Look far from the screen as often as possible.
Close eyes and visualize a large open area that makes you calm.
Minimize time on small, close screens and keep object far from eyes.
Read books over e-readers and keep the book as far away as visually comfortable.
Emphasize peripheral awareness before and after high attention tasks.
Change variable such as sounds or environment during high attention tasks.
Strongest memories are tied to emotions; more negative than positive.
If the limbic system is too active (such as in a threatening environment), prefrontal cortex activity goes way down. You can’t learn as well.
Cranial nerves are extremely important in social interaction. Nonverbal cues from these areas can unconsciously affect autonomics.
During adolescence (12-25) the right side of the brain and limbic system develop faster than the left and neocortex. This lateralization is why this time period can be so emotion-driven.
Face to face interaction is needed to cultivate the nervous system. This is the problem with social media and texting.
Dopamine pathways are very active during adolescence; it’s one of the reasons addictions start during this time.
Feelings of being overwhelmed are 6 times more common in those who have had concussions.
Rehearse making mistakes and how you will come out of them.
He also provided some great patient interaction nuggets that I hope to liberally steal.
Keep your eyes on the individual and tell them “it’s great to see you here.”
If you are not doing well on a given day – “I don’t feel good today but we’re going to have a good session.”
If you are at odds with a patient – “We’ve seemed to come to a roadblock. Would you agree?”
My big takeaway from psychologist Dr. Tracy Heller’s talk was mindfulness.
Mindfulness is something I am hoping to get more into in the future. She defines it as being aware of your thoughts, emotions, physical sensations, and actions in the present moment without judging or criticizing yourself or your experience.
It’s a big deal to have this capability. Practicing mindfulness has been shown to reduced cortisol, stress, pain, depression, and anxiety; while also improving memory, sleep, and cognitive function.
The way we build mindfulness is basically letting go. I like the analogy that I heard while using Headspace (a great app if you haven’t used it). Imagine your thoughts and feelings as cars in traffic. Your goal is to just watch the cars pass by, not chase them. You want to be present in the moment, as we want in most of life.
One option of practicing this is resonant frequency breathing, in which we perform 4.5-7 breath cycles per minute. Let the body breathe on it’s own and let the air come in; using terms such as “let,” “allow,” and “permit.” These are cues I have been using much more with patients and has made a big difference.
This was easily my favorite part of the symposium (I may be biased since my Dad gave this talk). Bill Hartman blew it out of the park teaching us how PRI applies at the highest level of performance.
The rules change in the performance realm because the patterns are incredibly powerful, effective, and efficient. In some cases we may want them. A perfect example that Bill gave: Usain Bolt
Rarely does he cross midline when he runs, making him the fastest runner on one leg. Do we want to change that? Probably not.
Performance does not equal health. Gymnasts for example, may need to create pathology to perform at a high level. Some people must utilize passive elements to produce greater outcomes. Usain Bolt runs on one leg. Everyone is a case-by-case basis. N=1 forever.
What must occur in the performance and health realm is stress management. Acute stressors with recovery make us antifragile; prolonged stressors reduce variability as an allostatic adaptation.
If one must constantly perform at a very high level, where will they be on this stress dichotomy? Prolonged stressors = reduced variability, sympathetic dominance, and system extension.
Variability helps us anticipate demand. It helps us become better able to cope with specific environments and recover movement function. The only way we can know if movement variability is present is through assessing the musculoskeletal system
“The state of the musculoskeletal system is the other end of the brain” ~ Bill Hartman
If stressed or threatened, body systems use default reflexive mechanisms to combat threat. The brainstem is much faster than the cortex. As a consequence, variability can be lost.
Attaining increased prefrontal cortex activity allows us to inhibit our default response and increase variability. That’s why mindfulness increases HRV, and that’s why a 90/90 hip lift can alter body position.
To better manage stress, we must train. Training is a progressive desensitization of threatening input to allow an athlete to perform at adaptive potential with optimal variability and without fatigue.
The higher performance level required, the more difficult it becomes to get neutral. This is what happens during functional overreaching. You gain higher performance output during this timeframe because the sympathetic nervous system and HPA axis are on overdrive.
Applying Bill’s principles along the training and rehab continuum, rehab requires neutrality and variability to rebuild a failed stress tolerance. The amount needed in performance realm will depend on how (in)variant one’s sport is.
The Wild World of Combat
Dallas Wood and Zach Nott work with in a military population, and it was fascinating showing how they mitigate the extension necessary for their clientele to perform. They guys collect a lot of data, and the fun factoid was that about 80-90% of their individuals are PEC and bilateral BC (surprise surprise).
They showed us a very cool auditory case. They had a dude with a PEC/BBC presentation with a history of ear trauma and tinnitus. When they blocked his left ear the gentleman was completely neutral.
Treatment underwent reducing the tinnitus by implementing a hearing aid that uses various white/pink noises to slowly reduce tinnitus. Not sure exactly how it works, but this was exciting to hear about (ha). I look forward to learning where PRI takes auditory integration.
So there you have it. I already signed up for next year’s symposium because this one was so much fun. I look forward to more of the consistently fantastic content that PRI provides. Learn on!
Lori is a very good friend of mine, and we happened to have two of our mentees at the course as well. Needless to say it was a fun family get-together.
Lori was absolutely on fire this weekend clearing up concepts for me and she aptly applied the PRI principles on multiple levels. She has a very systematic approach to the course, and is a great person to learn from, especially if you are a PRI noob.
Here were some of the big concepts I shall reflect on. If you want the entire course lowdown, read the first time I took the course here.
Extension = Closing Multiple Systems
This right here is for you nerve heads.
It turns out the pelvis is an incredibly neurologically rich area.
What happens if a drive my pelvis into a position of extension for a prolonged period of time?
I’ve written a lot about how Shacklock teaches closing and opening dysfunctions with the nervous system. An extended position here over time would increase tension brought along the pelvic nerves. Increased tension = decreased bloodflow = sensitivity.
We can’t just limit it to nerves however, the same would occur in the vasculature and lymphatic system. We get stagnation of many vessels.
Perhaps we need to think of extension as system closure; a system closing problem. Flexion will be the solution to open the system.
Pausing after an exhalation gives diaphragms time to ascend. Diaphragmatic ascension maximizes the zone of apposition (ZOA). The better ZOA we have, the less accessory musculature needed to take an adequate breath.
The two important ZOAs needed in this course are at the thoracic and pelvic diaphragms. We want to build synchronicity between these two diaphragms.
The way we do that is through the pelvic inlet.
The inlet links and adequately positions these two diaphragms via internal obliques and transversus abdominis (IO/TA).
To determine how this occurs, we must look at how breathing affects musculature.
This part here was a huge lightbulb moment for me. Muscle lengthening correlates with inhalation, and muscle shortening correlates with exhalation. So to create a stretch in areas you wish to lengthen, you may want to inhale, and to increase muscle contractility, you may with to exhale.
[Note: This is one reason in lifting exhalation is during the concentric phase and inhalation is during the eccentric phase?]
Now lets apply this concept to the pelvic inlet in an extended system. Let’s say the left innominate is forward (a LAIC pattern). My left IO/TA on would be eccentrically lengthened and in a state of inhalation. The left thoracic and pelvic diaphragms would be tonically active and form a v-shape.
This dyssynchrony explains why certain pelvic and thoracic tests correlate. The LAIC pattern suggests that I would not be able to adduct my left hip.
At the pelvis, this would occur because I have a “long” left anterior outlet and “short” posterior outlet.
The outlet and the thorax reflect one another. In this case, my anterior outlet is equivalent to the ipsilateral anterior chest wall and my posterior outlet is equivalent to the posterior mediastinum.
Guess what the tests will look like? I will have good left apical expansion and limited left posterior mediastinum expansion. I can’t adduct my left thorax or abduct my right thorax, much like I can’t adduct my left hip or abduct my right hip. These tests look at the same thing the pelvic tests do.
The Definitive Word on PRI Squatting
We can look at one’s ability to actively synchronize the thoracic and pelvic diaphragms by one’s ability to squat.
The functional squat test is an excellent way to show if one is capable of maximal pelvic diaphragm ascension and can shut off extensor tone. It also is a test to see if one has a patho-compensatory pelvic floor; for if you can squat but can’t adduct your hips, you gotz problems.
Here is what the functional squat test is not: a position to go under load in the weight room.
The above was straight out of Lori’s mouth. So to all the people who talk smack about the PRI squat, your answer is above. It’s not looking at the same thing as a max effort back squat.
Here’s how to test it.
Sitting is Hahhhd
In PRI land, sitting is the most challenging position to be in.
Why? Because there are less points which one can reference. Sitting unsupported requires proprioception exclusively on your ischial tuberosities. Success here relies on alternating and reciprocal muscle recruitment. If I don’t have this, I will extend.
Some Quick Postural Eyes
Lori is a great at predicting how dynamic movements will look on the table. Here were a couple things that stood out to me in this regard, as well as a couple other random things.
Leg whipping means an individual likely has a femur stuck in adduction.
Patho-compensatory people usually have more narrow hips. Could possibly be more common in males for this reason.
People who lean to one side in gait need a glute med.
If one cramps during an exercise, think inhibition. We’d rather shaking.
Glute med is the needed ligamentous muscle if a hip subluxes laterally.
Furniture is made to fit people who are 5’8.
Hard orthotics = overrated. We want a soft heel cup and arch to be used proprioceptively.
“I like to refer to myself as your coach.”
“You can’t work the same muscle in a different position and expect the same outcome.”
“You know I’m going to have to spend some time on this little booger.”
“If you want to give more pelvic instability stretch hamstrings.”
“She trusts me and I make her shake which is all good.”
“PECs cannot breathe to the high moon.”
“Getting neutral is not treatment.”
“Her back needs to go on a holiday.”
“Run with ribs.”
“When you go run, run.”
“We like extension, just not 24 hours a day 7 days a week.”
“If your patients cannot breathe correctly, don’t do a PRI activity. They will fail.”
“Not everyone needs a pair of glasses. Some people need a diaphragm.”
“I’m not a comedian. I’m here to teach you.”
“We’re [the clinician] not in control. We’re just invited to the party.”
“I get excited when I feel my right glute max burn.”
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.
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.
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.
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”
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”
“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.”