It’s the Salient Detection System, Stupid

I feel your [insert whatever output your brain decided to use to defend against an excessive stressor].
I feel your [insert whatever output your brain decided to use to defend against an excessive stressor].
 Can you tell the difference among pain, depression, and pleasure?

From a neurotransmitter perspective, the answer is no (see here and here).

How is it that three very different states can be so neurologically similar?

I feel the commonality that the nervous system purports reflects a system that responds to stimuli that are deviations from the norm. We call these instances by this word:

Salient.

Doesn’t that make your loins quiver?

I know mine do
I know mine do

Let’s discuss how it works. Here’s your recommended reading.

1. The pain matrix reloaded: a salience detection system for the body (Thanks Sigurd)

2. Stress signalling pathways that impair prefrontal cortex structure and function (Thanks Son)

3. From the neuromatrix to the pain matrix (and back)

[Note: Most of this article is an amalgamation of the three articles that I cited above and my own thoughts. Rather then cite every sentence AMA-style, I’ll give the credit to these guys above. Read ‘em and figure out how I put this together. For those who are sticklers for proper reference formatting, the type I am using is KMA-style citation.*]

The Pain Neuromatrix Myth

Hate to break it to you, but pain ain’t so special. Here’s why.

Mr. Rogers lied to you pain.
Mr. Rogers lied to you pain.

If you follow modern pain science, you may often hear the term pain neurosignature or neurotag. This phrase is meant to describe a cluster of brain areas that are active during a pain experience.

Information that can contribute to a pain experience travels to several areas. Some of the big players are the primary and secondary somatosensory cortices (all the talk about the homunculus), the anterior cingulate cortex (ACC), and the insula to name a few. These bad boys are consistently active when pain from a nociceptive stimulus occurs. Hence, these brain areas are considered to be part of the pain neurotag present in us all.

However, this theory has a couple problems. First off, there is no brain area that exclusively responds to nociceptive stimuli. That includes the aforementioned locations.

In fact, these areas have been shown to simultaneously activate by the following sensory inputs: nociceptive, somatosensory, auditory, and visual. This variety can be explained by the vast array of wide-dynamic range neurons; neurons that carry multiple inputs to cortical areas.

The suggestion: the supposed “pain neuromatrix” can respond to a wide variety of sensory inputs. I don’t think the input matters much at all. This fact takes the quote “nociception is neither necessary nor sufficient for a pain experience” to a completely different level. I like this instead:

 “Any input is not necessary, but sufficient for a pain experience.”

As if pain wasn’t complex enough.

It doesn't matter what input you had!
It doesn’t matter what input you had!

[Interesting side note: nociceptive specific neurons have been shown to be active when a threatening visual stimulus occurs. How many of you folks who treat pain are asking about vision? Maybe there is something to that PRI after all.]

So how is the pain neuromatrix demolished? Because of the first point I mentioned in this post. We could also see a wide variety of outputs that neurologically appear similar to pain occur. The neurosignature is not always exclusive to pain.

Let’s rephrase our quote again.

“Any input is not necessary, but sufficient for any output.”

What would constitute a change in output that resembles what was once thought as the pain neuromatrix? Here is where salience comes into play.

She said the word salient and I...
She said the word salience and I…

The Salient Detection System

A salient stimulus is something that stands out relative to the background. The intensity is irrelevant; the key is how different the input is. These inputs can occur within the body or the environment.

An elephant in a room is salient. A room full of elephants is not.

Unless you are a republican here.
Unless you are a republican here.

But here is a more scientific example. One study mentioned in the articles used a monotonous nociceptive laser stimuli interspersed with a novel nociceptive stimuli of various physical properties. Larger activity in the “pain matrix” areas occurred when the novel stimulus was applied, regardless of how intense this was.

 Deviation from norm is what is necessary for this system to activate. Let’s upgrade our phrase again:

 “A salient input is necessary for an altered output.”

Being able to respond to salient inputs helps one adapt to environmental and body changes. This is why nociception can be powerful, as it is a very salient stimulus.

Because there are no brain areas that respond exclusively to nociceptive stimuli, the brain areas typically involved in “the pain matrix” are more likely involved in an all-encompassing salient detection system. The outputs that occur are the brain’s best guess at how to adapt to this new stimulus. As to why one output may occur over another is likely beyond our current knowledge base.

Unfortunately sometimes your brain has similar accuracy to Batman being riddled by the Riddler
Unfortunately sometimes your brain has similar accuracy to College Humor’s Batman.

It Comes Down to Threat

If you haven’t read before, I believe that stress/threat that goes beyond our system’s capacity (i.e. is salient) is ultimately what leads to many of the outputs we see clinically.

Let’s see this process in action. Let’s suppose you are exposed to a threatening salient stimulus.

When a severe stressor occurs, the prefrontal cortex (PFC, our decision-making center) decreases its activity and the amygdala takes over. The amygdala likes predictable behaviors, so habitual strategies will run to combat this stressor. This is the stuff you are good at.

My go-to when I'm in danger.
My go-to when I’m in danger.

If the PFC is active, we consider that top-down control. When exposed to a threatening salient stimulus, bottom-up processing via the amygdala is more dominant.

Stress and inflammatory hormones flooding the system compound this shift, which strengthen the amygdala and weaken the PFC.

Getting Stuck in the Cycle

Let’s suppose you are exposed to a threatening salient stimulus and are fortunate enough to survive. Your brain will ask the following question:

“How do I prevent that from happening again?” ~ Your brain

The major players here are dopamine and norepinephrine.

And these neurotransmitters play from far and wide
And these neurotransmitters play from far and wide

Whatever output was successful in threat attenuation will be positively reinforced by the amygdala. Our reward neurotransmitter known as dopamine increases its presence when a stressor is applied. Outputs used during that stressful situation will be captured and rewarded for occurring. Over time, this process can contribute to chronic outputting (pain, addiction, PTSD, etc).

If pain fear-avoidance reduces threat, reward. If anxiety keeps you protected, reward. If snorting a mountain of coke keeps you happy-go-lucky, reward.

My choice of course.
Where do you think all that blog money goes?

To me, the above outputs are the same thing. The outputs that become chronic depend on if maintaining chronicity ensures one’s survival.

Norepinephrine, our neurotransmitter that gives us that adrenaline rush, initially drives us sympathetically to combat that threat. However, in chronic stress environments such as those mentioned above, norepinephrine will begin to fire to irrelevant stimuli. These changes can now make inputs that were once nonthreatening threatening.

Going from Vicious to Delicious

So we are stuck in a bottom-up amygdala-happy cycle. How do we get out of it? PFC is the hero we deserve so we can hope to stimulate top-down activity.

But not the one we need right now.
But not the one we need right now. Can never have enough Batman references

We have a problem though. When we have a chronic x, y, or z, working memory over-attends to inputs that perpetuate said output. It takes over our working memory. Individuals stuck in a chronic cycle have a hard time getting out of this state because the output occupies the mind and is rewarded by dopamine.

There’s only one way to break the cycle: Salience.

A new, favorably salient input is necessary to encourage top-down processing. This is how our rehabilitation process begins.

Introducing a favorably salient input is only step one. This piece provides a window of opportunity for learning a new strategy, as the previous threat is reduced.

That’s why manual therapy must be incorporated with exercise. That’s why achieving neutrality is only step one, that’s why therapeutic neuroscience education stops benefitting after 3 months. That’s why a joke is less funny after the first time its told.

These examples are the same. All are novel stimuli that divert attention for a brief moment in time.

And they won’t work forever.

It doesn't seem that long until you grown...2 Batman + 2 OutKast references might equal the best blog yet.
It doesn’t seem that long until you grown.

[Side note: 2 Batman + 2 Outkast references = best blog yet]

When the system is flipped to top-down, one must introduce variability, capacity, and/or power to better attenuate future threatening inputs. When an individual’s sweet spot of these qualities is found, better stress management occurs. Those salient stimuli that push someone into an unfavorable bottom-up cascade are no longer salient.

The standouts just become part of the noise.

Last Remarks

We now have a neurological framework for which we can treat individuals who are under threat, and the common link among all these folks is salience. Recognizing what salient detection means, and creating better body-spatial environments to combat threatening salient inputs, may be a major factor in reducing some of the chronic conditions we see.

Now that’s a cool system…

Pin for sale soon at zaccupples.com
Pin for sale soon at zaccupples.com

 

 

 

*KMA = Kiss my ass**
** Granny would be proud

 

 

 

 

The Road to an Alternating and Reciprocal Warrior: Wisdom Teeth Extraction

This spans an entire treatment over a year’s time.

Here’s part 1

Part 2

Part 3

The Saga Continues

I’ve been through vision, I’ve had dental integration, I’ve put in the PRI activity homework, maximized my PRI testing, and feel a new man.

I know frontal plane
I know AF IR

Yet neutrality eludes me. It is a state of mind I could once feel by the power of glasses and splints, but the nervous system learns and accommodates. I topped out.

But of course, I knew that would be the case from my very first session with Ron.

“You gotta get those wisdom teeth pulled.” ~Ron Hruska

By virtue of the dentist I integrate with, the time came. And here are the results.

Extract time.
Extract time.

Zac B.E. (Before Extraction)

So at this point in my life the large HRV gains I initially had were dropping and I was still having some neck tension. Training was feeling so-so.

Test-wise, the videos below show what I look like.

Here’s my squat

And my toe touch.

Upper quadrant tests

And lower quadrant tests

Mandibular movements

And some cervical movements

My pelvis is consistently neutral and I can shift and squat with the best of ‘em. But I still present with restrictions in my thorax, neck, and mandible (BBC/RTMCC).

These limitations are likely present because of a  bony block called wisdom teeth.

The enemy reveals himself
The enemy reveals himself

As you can see, the maxillary (top side) wisdom teeth limit the excurision of my lateral pterygoids for lateral trusive movements. My hope is by removing these guys I will get access to more frontal plane, which should clean, up my remaining tests.

Operation Extraction: 1/30/15

By the way, 3D CT machines are the coolest thing out there. Definitely putting on my amazon wishlist.
By the way, 3D CT machines are the coolest thing out there. Definitely putting on my amazon wishlist.

I enter the room to get prepped for surgery, and the worst possible thing occurs.

Country music is playing.

7529bed6557dc022221851f82c0a8a52
Immediate amygdala hijack

And I can’t have that!

So I politely ask one of the workers there if we can play something a bit more soothing prior to my surgery.

2pac “I ain’t Mad at Cha” begins playing.

That’s more like it.

Could not think of a better way to reduce threat.
Could not think of a better way to reduce threat.

I get the IV put in, hear some Juicy by Biggy, and pass out from the Mind Eraser anesthesia. Yes, it was actually called “Mind Eraser”, and yes, I remember nothing.

Like this happening

Evidently I really wanted this picture taken
Evidently I really wanted this picture taken

And definitely not this

But I do remember looking like Marlon Brando for a period of time

What was really cool about the whole experience is how little pain I felt. I probably took 2-3 pain pills at most. I think this is because I was actually excited about having this surgery done, and the reward I was hoping to get far exceeded the nociceptive information I would inevitably receive.

Just goes to show it’s all about threat perception.

#explaindentistry Should I pitch this to Adriaan?
#explaindentistry
Should I pitch this to Adriaan?

Zac A.E. (After Extraction)

I waited to re-measure and assess until 6 weeks later. This way I had to some time to heal and adjust to this new sensory experience. My exercise program basically consisted of squatting, alteranting activity, and mandibular lateral trusion to feel my pterygoids.

The cons are I no longer looking like Marlon Brando, but the pro’s are the mobility gains. Check it out in the vids below.

Here are the standing tests

My upper quadrant tests

Lower quadrant tests

Here are my mandibular movements

And lastly, cervical

Since surgery I’ve been hovering between a right BC and superior T4. I consider myself no longer a TMCC patient because mandibular movement is now fully restored. The thorax position can limit cervical axial rotation.

In terms of how I feel, neck tension has been significantly reduced, especially with jaw movement. The only time I get the tension is when I am training hard or if I am reading/sitting for a real long time.

I also produce a crap-ton more saliva, which comes back to the very first question Ron asked me when I started this process. You don’t know what this stuff will affect.

Me like all the time now
Me like all the time now

Consequently, I have noticeably much more phlegm in my saliva and feel way more congested than ever. Sleep quality does not seem as good, as I have generally felt a bit more tired throughout the day.

So what gives? My thought was the wisdom teeth would be the final piece of my PRI quest, but I did not get all the changes I was hoping to get. Was Ron wrong? Did I get less wise for nothing?

I did not lose my wit and charm though. Sorry Ron, better luck next time.
I did not lose my wit though. Sorry Ron, better luck next time.

The one consistent thing that I am still limited in is the cervical rotation and shoulder horizontal abduction. I am hesitant to perform any pec inhibitory activities because I have been neutral in the past. I don’t want to “stretch” something that doesn’t need stretching.

I look over my 3D CT scan that I got at the dentist office, and one thing stands out. I find my limiting factor:

Not your run-of-the-mill tissue extensibility dysfunction
Not your average tissue extensibility dysfunction

The journey continues.

 

 

 

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.

 

Favorable Inputs: A Model for Achieving Outcomes

One Hot Model 

Louis Gifford’s Topical Issues in Pain has an amazing amount of quality information, and has really inspired many thoughts.

I’ve only read book 1 thus far, but this book can generate material to expand upon much like Supertraining does for fitness writers.

Or what Rakim did for your favorite rappers.
Or what Rakim did for your favorite rappers.

I’m sure many of you folks have seen this picture before.

Bet you never saw this pic of (your) mom
Bet you never saw mom like this

Gifford called this schematic the “Mature Organism Model” (MOM) to illustrate how pain works.

Inputs from the tissues and the environment travel up the spinal cord to the brain. The brain processes these inputs and samples information from itself to generate a corresponding output. These outputs are perceived as new inputs which reset the cycle.

MOM was of course used to illustrate the three pain types (read here and here), but it is so much more than that.

The MOM is a schematic for how the nervous system works.

How do you like how that shit works?
How do you like how that shit works?

Any input that is processed by the brain may or may not lead to outputs of altered physiology and/or behavior.

Viewing (your) MOM (ha) made me think a lot about working with individuals who are dealing with a threat response. How exactly are we helping these folks?

I’ve come to believe that we do not treat outputs. At best we can only provide inputs that we hope are exchanged for new, desirable outputs. In patient care, we are hoping to alter perceived threat. We attenuate threat by giving an individual favorable inputs, which we hope leads to favorable behavior and physiological changes.

Let’s look at what these favorable inputs are by looking at MOM a bit more in-depth.

An I'll be the motherlover
Yes, I am a motherlover.

The Three Inputs

Deal with it CS Lewis
Best shot at winning Natalie Portman’s heart…deal with it CS Lewis

The nervous system can receive information from body tissues, the environment, and itself. Therefore, these are the areas in which we shall provide favorable inputs.

The three input types that can favorably affect the nervous system are:

  1. Therapeutic Interventions
  2. Therapeutic Interactions
  3. Therapeutic Reframing

These inputs can be provided by the individual themselves, someone else, or a foreign object. All three will be needed to some degree, but some will be needed more than others depending on the goal. Let’s dive further.

And now I give away the entire post.
And now I give away the entire post.

Therapeutic Interventions 

This input occurs by providing information through tissue receptors. Input types will include most conventional and alternative medicines and performance training.

The primary things we are looking to change with these inputs are:

  • System variability – The range at which a system can act
  • System capacity – The volume a system can perform with.
  • System power – The intensity a system can perform with.

Life is a balance between these three system components, and the degree to which a system must have these components is tailored to an individual’s needs. (ps, my Dad is going to talk about this much better than I here).

Since I am assuming most of my readership is in the movement business, we can look at the movement system.

Movement variability is the ability to move through full ranges of motion actively and passively in three planes. Variability in the movement system follows a bell curve, with movement rigidity for our hypomobile folks and pathological movement variability for our hypermobile folks.

 variability

Most conventional therapies that aim to improve mobility and motor control are typically dealing with movement variability. To me, the best system for managing movement variability is PRI, as it is the only one that looks at one’s ability to move well in three planes.

Movement capacity would be how long one can perform before fatigue. Think of any type of training that gets you to do something longer (e.g. aerobic conditioning) as capacity training. In the PT realm, I see graded exposure the way Butler, Louw, and other pain science advocates espouse as building capacity. This training methodology is no different from your favorite conditioning methods.

Movement power would be increasing the force produced in a task. Think weight training and the like.

Therapeutic Interactions

 The target input here is the individual’s environment, and I would argue that this is the most important, and sadly under-discussed, input that a clinician utilizes.

This input’s goal is to create an environment that allows for desired outputs to occur.

If you are a clinician treating someone in pain, you are going to be friendly, funny, empathetic, and an excellent listener (and do stuff I wrote here). Your clinic may have calming colors and scents, and you may want to boot out family members that stress your client out.

Or maybe the whole family...Forever.
Or maybe the whole family…Forever.

If you are a coach getting someone strong, you’ll probably want a bunch of like-minded clients working together getting amped up and playing “my mother never loved me” music.

Aka every training session with Lance Goyke.
Aka every training session with Lance Goyke.

If you are an individual who lives in a stressful environment, you might change that input by leaving that stressful environment, changing jobs, moving to Arizona, etc.

Therapeutic Reframing

Here we are providing an input that affects the brain’s self-sampling; the mindset. Knowledge is power. The most common discipline that utilizes this input is psychology.

In the movement realm, this input is where therapeutic neuroscience education fits in. This methodology expunges old, deleterious thoughts while simultaneously providing the individual with new, nonthreatening thoughts. This exchange can reduce threat from other inputs.

We provide favorable inputs this way anytime we learn something. Every time you read something educational you are creating new inputs for the brain to sample.

Overlapping Inputs 

"But Zac, what about..." I'm getting to that.
“But Zac, what about…” I’m getting to that.

Categorizing an input depends on primary intent, but there are several instances in which inputs overlap. We should categorize these inputs via primary, secondary, tertiary intent. For example:

  • Putting a hand on someone while they are crying (Primarily therapeutic interaction as you provide an environment for healing; secondarily therapeutic intervention because the touch may provide a calming effect on the nervous system through cutaneous receptors).
  • Telling a funny story to educate someone (Primarily therapeutic education because that individual is being provided new beliefs; secondarily therapeutic interaction by making the client laugh).

Last Remarks

This favorable input model provides some insight as to how our clinical/coaching processes can affect the outcomes we seek. While we may have our strengths, creating desired adaptations requires excellence with all three of these inputs.

The best exercise program in the world will not be effective if a client does not does not like you just as your niceness will not outdo your outdated treatments.

Though I predict lobotomys will make a comeback in 2015.
Though I predict lobotomys will make a comeback in 2015.

Which of these three inputs do you excel at? Which need work? Comment below.

 

Course Notes: PRI Cervical Revolution

Where are all the People?

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

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

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

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

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

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

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

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

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

Let’s go through my big a-ha moments.

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

Smudging 901

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

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

We need to be able to differentiate our parts.

Neck Problems Do Not Exist

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

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

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

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

Two TMCC Possibilities

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

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

The Left Sidebend

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

It looks like this:

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

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

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

Right Torsion 

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

It looks like this:

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

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

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

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

Splints on Splints 

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

The PRI MOOO

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

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

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

The Gelb Splint

My muse.
My muse.

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

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

The EMA

ema

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

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

ALF Orthotics

The one and only
The one and only

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

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

C’est Fini

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

Infamous Ron Quotes

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

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 Post Wonderful Time of the Year: 2014 Edition

And That’s a Wrap

It’s that time of the year that we get to look back and reflect and what posts killed it (and which bombed).

It seems as though my fine fans be on a pain science kick this year, and rightfully so. It’s some of the best stuff on the PT market right now. It’s definitely a topic I hope to write about more in the coming year, and one I will be speaking on at this year’s PRC conference.

But without further ado, here are the top 10 posts of 2014.

10. Treatment at the Hruska Clinic: PRI Dentistry and Vision

Lift scores 6/5 with the Bane mask on. #alternatingandreciprocalwarrior
Lift scores 6/5 with the Bane mask on. #alternatingandreciprocalwarrior

Going through the treatment process as a patient has really upped my game in terms of knowing when to integrate with my patients. It has also been a life-changing experience for my health and well-being. Learn how they did it for me.

9. Course Notes: THE Jen Poulin’s Myokinematic Restoration

She's a myokinematic beast!
She’s a myokinematic beast!

So much fine tuning occured the second time around. I love how Jen acknowledged the primitive reflex origin of the patterns, as well as fine tuning both lift tests. She’s an excellent instructor (and fun to party with)!

8. Treatment at the Hruska Clinic: Initial Evaluation

Producing so much saliva
Producing so much saliva

The start of my alternating and reciprocal saga. Made for one of the most fascinating evaluations I have ever experienced. Ron Hruska is otherworldly.

7. Course Notes: PRI Postural Respiration

Chiari malformation waiting to happen.
Chiari malformation waiting to happen.

I love a good foundational course taught by the Ronimal. You always get a few easter eggs that allude to higher level courses and concepts. A must-take course.

6. Course Notes: PRI Craniocervical Mandibular Restoration

Ron looks even better in person with the meat suit.
Ron looks even better in person with the meat suit.

One of the most powerful and humbling courses I have ever been to. Ron goes all out on this course, as it is his baby. What dental integration can do to a system under threat is a concept that I hope is further explored in medicine. We can’t do it alone folks.

5. The End of Pain

Still verklempt by the overwhelmingly positive response.
Still verklempt by the overwhelmingly positive response.

This post marked a shift in my thought process and a realization of the possibilities that an integrated health system can accomplish. I have high hopes for our profession, and feel excited that an original post had so many views.

4. Course Notes: PRI Pelvis Restoration

A good group to learn from and with.
A good group to learn from and with.

It seems that with each PRI course you take you go another layer down the rabbit hole. Pelvis is a great course to link up Myokin and Respiration; especially with Lori and Jesse at the helm.

3. Course Notes: Dermoneuromodulation

Diane is bullseye with her neuroscience.
Diane is bullseye with her neuroscience.

Couple the best manual therapy explanation I have come across and a gentle technique and you get a rock solid course. The only downside is that now Diane has tarnished any other manual therapy course for me, as I can’t rationalize any other explanatory model given.

Fine by me.

2. Course Notes: Therapeutic Neuroscience Education

Stayed hungry to learn ever since this course.
Stayed hungry to learn ever since this course.

I love Adriaan’s practical application of pain education to patients, and he is one of the best speakers in the biz. There’s a reason why I am hosting him again next year.

1. Course Notes: Explain Pain

A legend
A legend

A great neuroscience course, a great practical course, and getting to learn from a PT legend? Sign me up.

Game Over!

And that marks the last post of 2014. Which were your favorites? Which are you hatin’ on? Comment below and let’s hope to even better content in 2015!

496d30611f94277eee71b80e3cd0f24cb9

Course Notes: PRI Integration for Baseball

Another Course in the Books

Back in November I had the pleasure of attending a new Baseball PRI affiliate course, taught by my homies Allen Gruver and James Anderson.

Ahh Cristal, my Moto, and a couple of PRI courses, why not?
Ahh Cristal, my Moto, and a couple of PRI courses, why not?

I really enjoyed this course because it was such a high-level affiliate and great prep for my PRC. We went into great deal regarding position, throwing mechanics, and treatment.

A…lot…of…stuff.

One of the most amazing pieces of the course was Allen’s ability to breakdown complex baseball movements into their basic biomechanical bits, And from that point show what compensatory things could occur if limitations are present. His eye for these things is unreal.

That piece of the course is a post or two on its own, so I won’t touch it here. In fact, I probably won’t touch it at all. Go to this great class and be wowed by Allen. You will be motivated to become a better clinician. I know I was.

Here are some of the big takeaways.

PRI 101 v 3.0

I’ve heard this overview three times this year now, and it is amazing that I still pick up things from it. James really outdid himself here.

The big piece this time around was space. We want space maximized.

Which is why I sit like this all the time.
Which is why I sit like this all the time.

In the vision course we discussed maximizing left peripheral visual space because the pattern reduces this quality. The pattern in general reduces our ability to move through triplanar space.

There are a few other reasons that we would be unable to shift into our left side. Overactive muscles chains may prevent this action, but we also have something very large occupying the left side.

We call this thing air.

If we are hyperinflated in particular areas (think left chest wall), how can we expect to go to the left side? Left space is already filled with air. Airflow must be transferred to the right side in order for us to maximally close down our left. Maximal left sided closure via a zone of apposition is necessary to create true left stance.

Closure-Bro-I-need-it

Patterns, Adductors, and Pecs (Oh My)

The right adductor magnus and left pec major, though not part of the LAIC/RBC pattern, are still very active muscles. Why is this so? These muscles prevent falling over when in right stance with left trunk rotation.

That PRI Doesn’t Work, I Got Someone Neutral and they Felt Worse

False! Here’s why.

An individual’s norm when under threat is the LAIC/RBC/RTMCC pattern. It’s autopilot; it’s what’s comfortable.

If frontal plane is Bob Ross, then LAIC/RBC is Ben & Jerry.
If frontal plane is Bob Ross, then LAIC/RBC is Ben & Jerry.

Let’s say you take that away from someone. They have greater movement freedom, but are not sure what to do with it or how to control it. This change could be perceived as a threat by the brain, and symptoms may increase as a means to prevent movement exploration into this new space.

I tell my patients when this happens it is like they just got their driver’s license and I gave them a Ferrari.

With some patients this is probably a bit more accurate.
With some patients this is probably a bit more accurate.

A Ferrari is a little more challenging to drive than most cars (so I hear, that blog paper hasn’t hit that level yet), so it’s going to be a bit harder to handle. Once the patient learns how to drive the Ferrari the possibilities are endless.

They must learn a new pattern (RAIC/LBC/LTMCC) in a nonthreatening manner so they obtain locus of control in this new position. Once integrity is achieved here, alternating reciprocal activity is ingrained to maximize movement variability.

Pattern Pitching Problems

#alliteration
Pitches ain’t shit

Depending on what arm you throw with, you are going to have a bit more trouble with certain aspects of pitching movements. I won’t go into the bazillion reasons why this happens like Allen did (go to the course yo), but here is what each throwing phase needs.

Righties

If I’m a right-handed pitcher, the LAIC/RBC is going to limit me. Let’s break it down to each throwing phase:

  • Wind-up – Need to turn on right posterior glute med to delay LAIC activity.
  • Stride – Need to inhibit right adductor and QL to maximize stride length.
  • Cocking – Need to shift into Left AF IR while maintaining right trunk rotation.
  • Acceleration – Need to keep Left AF IR in trunk flexion.
  • Follow through – Need to balance into left AF IR.

EddieButler_Fastball

South Paws

If I’m a left-handed pitcher, the RBC, posterior mediastinum, and timing will be my largest limiting factors. Here is what I need at each component of throwing.

  • Wind-up – Need to load left AF IR and engage abs to stay back. Inability to do this is what creates that beautiful natural spin us lefties have when we throw.
  • Stride – Need to inhibit LAIC/RBC so one does not rotate too early into Right AF IR and right trunk rotation
  • Cocking – Need to control Right AF IR and left trunk rotation while reducing back extension and keeping adequate left posterior mediastinum activity.
  • Acceleration – Need to keep trunk closed down into flexion
  • Follow through – Need to balance into right AF IR.

p6JtUqi

Repetitive Rotation Superior T8 (Gasp)

This part was probably the most controversial and misunderstood piece of the course. The concept itself is not difficult to understand, but the material may seem challenging to fit into the PRI philosophy.

I’ve had several discussions with James Anderson on this topic to make the masses get the most up-to-date explanation for this pattern. Here is what we came up with [My post-conversation thoughts will be in brackets].

In the first two baseball courses, “repetitive rotation superior T4 syndrome” was used to describe a rare compensatory pattern seen in particular populations. James and Allen are now calling this pattern “repetitive rotation superior T8 syndrome.” The name changed because there are more ribs reversing the underlying LAIC/RBC pattern then the top 2-4 ribs. This change will be in all future baseball course manuals.

And now for the condition itself. There are certain instances, albeit rare, in which certain individuals may appear to have a reversed postural pattern (RAIC/LBC). Repetitive right trunk rotation occurs via various trauma and/or functional demands, such as the deceleration thru follow-through pitching phase for a lefty or the back swing for a right handed golfer, creating a thorax that is driven to the right.

You can also see this in PRI junkies who bias the left side only and never alternate [Like a right-sided hemineglect neurologically. If right-stance activities are not appreciated, variability may lowered possibly due to disuse. One possibility for this is also losing appropriate right zone of apposition while in left AF IR, to which I will discuss in a future post].

This T8 syndrome differs from classic superior T4 because more drivers push the thorax to the right and externally rotate the right ribs. In the T4 case, the scalenes elevate the upper 2-4 ribs to meet excessive respiratory demands. In T8’s case, the left BC kicks into high gear and drives more of a PEC/bilateral AIC pattern. It may mimic a RAIC/LBC, but not be the case.

With the thorax rotating hard to the right, the pelvis and lumbar spine must orient left and into a pseudo-left AF IR translatory-type movement. Consequently, these folks stand and function quite well on their left leg compared to the right.

Seeing a “flipped” pattern is nothing to freak out about; there are still underlying LAIC/RBC patterning at play. This repetitive rotation superior T8 syndrome is an atypical compensatory strategy that requires atypical treatment.

Interventions basically flip normal PRI activities; shifting into right stance with left trunk rotation. We technically cannot call this “PRI” because the underlying human asymmetry is not addressed.

Treating in this fashion does however put the system into a “normal” asymmetrical pattern to which conventional PRI methods can be used. [That said, the name of the game has always been alternating and reciprocal activity. Everyone should be able to do traditional PRI activities on both sides without falling apart. The reason why this is not called PRI is because of the order treatment occurs in].

[The big message at the end of the day: Trust your measurements and treat accordingly].

Elbow and Wrist Drive Thorax

This portion was one of my favorite pieces of the course; namely because it’s not talked about anywhere else in PRI land.

There are 4 possible patterns on the left and right side that can occur at the humeral-radial joint; depending on the position of each.

I won’t go into details on each, but basically if you see increased mobility in one direction (supination or pronation), you likely want to inhibit that direction and facilitate the converse.

Wrist flexion, pronation, and internal rotation facilitate serratus anterior and contralateral thoracic rotation.

Wrist extension, supination, and external rotation facilitate lower trapezius and ipsilateral trunk rotation.

 Reference centers in the wrist and hand can also be used to facilitate position. When attempting to facilitate left stance with right trunk rotation, use a right pisiform and left palmar arch.

Dat’s It

So there you have it. Some of my favorite pieces from this excellent affiliate courses. It’s filled with a ton of information, and is easily the most challenging conceptually of the three affiliate courses I have taken. You won’t regret this one.

Unlike that one course...Or three (sigh)
Unlike that one course…Or three (sigh)

Great James Quotes

  • “If you see a forward head, hand them a card that says exhale please.”
  • “Inhaling in a state of exhalation is neurologically cool.”
  • “It’s not magic. It’s better than magic. It’s neurologic.”
  • “We’re gonna talk about trauma called throwing a baseball 95mph with your left hand.”
  • “That muscle firing is a total waste of sarcomere slide.”
  • “Your brain is a better parent of your body than I was my son.”
  • “Ron is looking at the brain, not the plumb line.”
  • “A plumb bob and grid is offensive to Ron Hruska.”
  • “What have you thought about the fact of never blowing up a balloon as a grown man?”
  • “He sucked a lot of balloons empty.”
  • “Hand on the heart for serratus anterior. Go ahead.”

 Gruv-y Allen Sayings

  • “You are only as good as your patient will allow you to be.”
  • “I can’t stand research to a point.”
  • “It depends.”
  • “The right QL and adductor are best friends…Just like James and I.”
  • “Don’t judge someone just by video.”
  • “You can’t make a program based on a screen.”
  • “If you’re not doing test-retest give them they’re copay back. You are failing them.”
  • “One pound dumbbells are not changing my patient’s lives.”
  • “We’re facilitating neurology.”

Course Notes: The Last Craniocervical Mandibular Restoration Evahhhhh

You’d Think I’d Learn it the First Time Around

You’d think, but CCM is one of the hardest PRI courses to conceptualize.

Story of my life
Story of my life

 It didn’t hurt that my work was hosting the Ron’s last time teaching this course, as next year we will see Cervical Revolution instead.

I took this course last February, and it’s amazing how different the two courses were. We had a room filled with PRI vets, and the Ronimal went into so much more depth this time around.

It was such a great course that I would love to share with you some of the clarified concepts. If you want a course overview, take a look here.

Three generations of...Oh sorry wrong family.
Three generations of…Oh sorry wrong family.

 The TMCC

 The right TMCC pattern consists of the following muscles with the following actions:

Cranial retruders/mandibular protruders

  • Right anterior temporalis
  • Right Masseter
  • Right medial pterygoid

Sphenobasilar flexors

  • Left rectus capitis posteror major
  • Left obliquus capitis

OA flexors that maintain appropriate cervical lordosis

  • Right rectus capitis anterior
  • Right longus capitis
  • Right longus colli

If this chain stays tonically active, then there is better accessory muscle respiratory capacity present. These muscles provide the fixed point needed for an apical breathing pattern.

Great for SCM day at da gym.
Great for SCM day at da gym.

We want the muscles on the other side, the left TMCC, to be active. Their activity will allow alternating reciprocal cranial function to be possible.

We also call this gait.

 Keep Ya Sphenoid Flexed

One cranial goal we have is to achieve sphenobasilar flexion, but what does this mean?

In the RTMCC pattern, the sphenoid is in an extended position. When the sphenoid is extended, the foramen magnum becomes larger and the spinal cord descends. This positioning explains all the chiari malformation jokes that we like at PRI-land.

Hence why I'm starting my Chiari brand clothing line. High heels shall be designed first.
Hence why I’m starting my Chiari brand clothing line. High heels shall be designed first.

This position would also create a forward head posture to create a compensatory airway. Consequently, occlusion may be altered.

The goal is to flex the sphenoid, which closes the foramen magnum and produces appropriate OA extension. This position keeps the brainstem happy.

 Lordosis is Important

 When the SCMs are overactive, especially on the left, a reversed cervical lordosis can occur.

If I see someone who cannot flex his or her neck, I’m not thinking of stretching them into flexion. I’m thinking about restoring cervical lordosis. If no cervical curve is present, then the neck is already at end-range. Stretching farther in this position could create potential pathology.

Lordotic position is achieved by the deep neck flexors listed above and maintained by a twisted levator scapula position under a foundation set by an active lower trap.

Things are just better when kept twisted.
Things are just better when kept twisted.

SCMs

 I learned to appreciate the SCM much more at this course.

In the RTMCC pattern, my OA joint is sidebent to the left. This position occurs due to the left SCM, rectus capitis lateralis, and levator scapula.

When an active left SCM is present, we usually see a corresponding frontal plane positional tug occur at the thorax and pelvis. Left SCM often works with the right quadratus lumborum and right adductor to push the sphenoid, sternum, and sacrum into a right lateralized state.

Pterygoids = Money

 When lateral trusion in protrusion is assessed, we are not really assessing jaw mobility but pterygoid function.

The left lateral pterygoid moves the mandible anterior and to the right no doubt, but it also moves the cranium posterior and to the left. We call this left acetabulofemoral internal rotation aka shifting into your left cranium.

I get the same look when I see lateral trusion restored.
I get the same look when I see lateral trusion restored.

This Really Bites

We discussed a lot about bites this weekend. One bite that would most certainly need dental integration is an anterior open bite. This bite is when the front teeth are unable to contact due to a very high palette.

I believe the technical term is nightmare.
I believe the technical term is nightmare.

This bite type would be the equivalent of rib flares on a PEC individual. When one has an open bite, the mandible retrudes far enough to increase pressure onto the mandibular condyles.

The TMJ essentially begins to act like a molar.

We also got to see an individual with a cross bite, in which the part of the teeth go so far inward that teeth contact occurs at an angle.

Not fun
Not fun

This positioning is very similar to the feet in a left AIC pattern. The right foot is in a supinated position, but the first ray will oftentimes create first ray plantarflexion to touch the ground. A cross bite is a similar phenomenon.

Other Fun Clinical Tips

  • The louder and earlier the click upon TMJ opening the healthier the joint is.
  • Front teeth contact keep temporal bones alive.
  • Back teeth keep head from going forward.

(in)Famous Ron Quotes

  • “I’m not interested in your 45 mm of opening.”
  • “I’ve learned one thing in life. Jaw surgery does not work.”
  • “I call it the quadratus eboli.”
  • “We’re going to talk about sciatica of the head.”
  • “You know, my mother is not so bad after all.”
  • “I want you to take this course because this is life.”
  • “I’ll say feeling cerebrospinal fluid is a bunch of you know what.”
  • “If you’re a mammal you suck. You suck as a mammal.”
  • “If you don’t suck you don’t have a neck.”
  • “Are you a mammal? No Zac you’re weird.”
  • “The IC lateral pterygoid. Oh sorry wrong course.”
  • “You didn’t know getting your IC adductor would help you taste Pepsi better?”
  • “Guess I’ll go to PT school. Maybe I’ll learn something there. NOPE!”
  • “The best thing you can do is invest your retirement dollars on CPAP machines and ambien.”
  • “The system knows everything.”
  • “This patellar, excuse me, temporalis region.”
  • “Buy some Bose headphones and listen to Lady Gaga. Wow! That worked.”
  • “I just walked you through evidence that has been there for years and no one can handle it. Oops.”
  • “Surely. Don’t call me Shirley…Sahrmann.”
  • “I’m not here to recapture someone’s disc…Oh but I am.”
  • “The biggest shim that anyone does is a heel lift and it makes me want to puke.”
  • “If you have one foot that pronates and one that supinates, you’ll need a podentist.”
  • “The number one concussion is the Iphone.”
  • “Salt, pepper, and left lateral pterygoid.”
  • “I want his pube to like his malleolus. Oh I didn’t mean that.”
  • “I’m probably about 1% there.”
  • “Because I’m not the maker.”
He's not Shirley Sahrmann but...
He’s not Shirley Sahrmann but…