Prompted by some mentee questions and blog comments, I wondered where manual therapy fits in the rehab process.
To satisfy my curiosity, I calculated how much time I spend performing manual interventions. Looking at last month’s patient numbers to acquire data, I found these numbers based on billing one patient every 45 minutes (subtracting out evals and reassessments):
Nonmanual (including exercise and education) = 80%
Manual = 20%
Modalities = 0%!!!!!!!!!!!!
Delving a bit further, here’s my time spent using PRI manual techniques versus my other manual therapy skill-set:
PRI manual = 14%
Other manual = 6%
As you can see, I use manual therapy a ridiculously low amount; skills that I used to employ liberally with decent success.
There’s a reason for the shift
I want my patients to independently improve at all cost and as quickly as possible. The learning process is the critical piece needed to create necessary neuroplastic change; and consequently a successful rehab program.
I know needling is quite the controversial topic, but I was amazed at the sheer quantity of evidence supporting this modality. Like, an insane amount. I am not sure what the “haterz” found their criticisms on, so please comment if you have some ammo (I am a noob to this after all).
And Ray’s lecture on dry needling mechanisms? Oooohhh lawwwwd. Easily one of the best foundational science lectures I have ever heard. Period. The passion this group has not only for science but the physical therapy profession is inspiring. They made me excited to be a PT. Perhaps even inspired me to contemplate the PhD route.
[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.
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.
[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.
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.
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.
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.
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.
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.
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.
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.
These examples are the same. All are novel stimuli that divert attention for a brief moment in time.
And they won’t work forever.
[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.
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.
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.”
I’ve only read book 1 thus far, but this book can generate material to expand upon much like Supertraining does for fitness writers.
I’m sure many of you folks have seen this picture before.
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.
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.
The Three Inputs
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:
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.
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.
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.
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.
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.
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.
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.
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).
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.
Which of these three inputs do you excel at? Which need work? Comment below.
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.
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.
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)!
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.
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.
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.
You can be amazed at what the patient can actually be do at this stage to expedite the rehab process once movement constraints are lifted.
The most common upper quadrant restriction involves no movement of the involved extremity.
The goals during this stage ought to include:
Promote a safe healing environment – reduce fear, pain, swelling, etc.
Restore local mobility
Restore system variability
Remap affected regions in the somatosensory homunculus
Challenge the aerobic system
Let’s take a patient I am seeing post-rotator cuff repair on his right arm. He cannot move his arm for 6 weeks.
Top priority of course is restoring range of motion, so session bulk was spent on pain-free manual therapy and passive range of motion. For home he gets elbow/wrist ROM and nerve glides.
But there is no way in hell I am doing that for 60 minutes.
There are many other things that this fellow can work on aside from basic range. Let’s address the other qualities.
Restore System Variability
In PRI-land, this gentleman was a PEC/RBC/RTMCC. We began to address this protective pattern day 1 after surgery.
Reduce sympathetic tone, reduce threat perception, promote a safe healing environment. Everybody is happy.
Since I knew he would be living in a recliner for the forseeable future, we kept things simple by blowing up a balloon.
One week later our guy came in as a LAIC/RBC with decreased left hip internal rotation, so we shifted our emphasis towards improving right apical expansion while shifting into his left hip.
With this strategy, we were able to maximize system variability within the confines of his restrictions. Gaining apical expansion on the right side was a nice way for the patient to relax the shoulder tissues while keeping the repair intact.
Remap Affected Regions
Use it or lose it reigns king in post-op land. But how can we get this gentleman to use his arm while respecting the passive-only barrier?
Here is where I love graded motor imagery the most. The shoulder’s motor pathways can still run while the repair stays intact.
He ended up blowing this stage out of the park, so once we went through all the different challenges this program allows we went straight to explicit motor imagery.
I asked our guy to visualize what his shoulder looked like without the brace first. Once he was able to do this, I had him imagine moving his arm in various movement planes, to progress to envisioning ADL performance with his affected extremity.
In the clinic, I would teach him push/pull movement on his left arm while he imagined performing those actions on his right.
Once he mastered imagery, we began to implement mirror box therapy.
We first started out by just watching him move his “right” arm in the mirror, which he said was very freaky.
Despite the freakiness, it blew him away how much this technique reduced his pain and stiffness.
Once he could do basic movements no problem, we had him work on push/pull movements using his left hand while watching his “right”arm.
His most challenging piece? Open loop arm movements. This task was a beast for his mind:
Combining GMI with working the non-affected extremity tremendously expedited re-learning basic movements on his affected extremity as we progressed later into postoperative care.
Challenge the Aerobic System
Our guy is in his 50’s and a blue collar worker, so we aren’t getting super wild and crazy here.
Day one we emphasized nice easy walking 20-30 minutes per day to increase circulation and promote healing.
Clinic-wise, we taught him squatting, deadlifting, pressing, and rowing. To emphasize the aerobic system, we kept things at tempo pace to emphasize slow-twitch hypertrophy and aerobic development.
2-4 sets of 10-12 reps
Pace 3 second eccentric—no pause—3 second concentric. I tell patients to say this mantra slowly – Screw…you…Zac (eccentric) Screw…you…Zac (concentric). This mantra also helps boost the immune system because patients find it funny. Two points for me!
30-40 seconds rests between sets.
Later Rehab Stages
The later rehab stages look somewhat similar to typical fare, though I do not emphasize isolated strengthening so much.
Once the active assist/active unresisted phase is allowed, we switch to that stuff. Shoulder remapping becomes a greater active process, so most of GMI is stopped. Let’s get him moving.
Our program also shifts toward him using his right extremity to aide in variability restoration. He has limited flexion, so I like a doorway lat stretch:
[side note: amazing that most comments I’ve heard on this vid involve my glutes and not the technique. Upon reflection of most of my life, this probably is not as surprising]
I also like him doing unresisted reaching:
We still emphasize challenging the aerobic system and the unaffected extremities, but this usually accounts for about 20% of the session at this time.
Once we can start resistance training the extremity, we keep things simple. I like push/pull movements and static/dynamic motor control exercises. So we teach our guys armbars, get-ups, carries, crawling, etc.
I don’t use a whole lot of isolated cuff work during the rehab process. The cuff doesn’t really work as a prime mover, so unless the goal is cuff hypertrophy (aka gettin’ Swolebodan Milosevic), I don’t do it.
In the cases that I have scrapped cuff isolation exercises, I still saw manual muscle testing improve just the same. So let’s teach the cuff to be a cuff.
We finish the rehab process by making it look a lot more like fitness. By the end, the hope is to have system variability restored, local mobility in the clear, and strength up to snuff. Teach your guys and gals the basic movements and emphasize patient-specific functional activities, and you are in the clear.
That’s where I am right now with upper quadrant post-operative care. There is a lot that these folks can be doing, and my challenge to you is to make those early stages of rehab some of the most exciting for the patient.
Several different thoughts have crept into to my mind sparked by what I have read and conversations I have had. I would like to share these insights with you.
I remember when I was visiting Bill Hartman Dad a few months ago and we were talking about a specific treatment that is quite controversial in therapy today. He said something that really resonated with me:
“Thus, pain can be viewed as a single perceptual component of the stress response whose prime adaptive purpose is to powerfully motivate the organism to alter behavior in order to aid recovery and survive.”
Notice what I bolded there. Pain is a single component of the stress response. Not the stress response. Not a necessary component of the stress response. Just one possibility.
Why do we place so much importance on pain?
Many proponents of modern pain science (myself included) often use this statement against individuals who are over-biomedically inclined:
“Nociception is neither necessary nor sufficient for a pain experience.”
Agreed, pain is not always the occurring output when nociception is present. That said, pain is only one of several outputs that may occur when a tissue is injured. Just because pain is absent does not mean other outputs are also absent.
Many different outputs can occur when an individual is under threat.
Let me propose a new quote to those who focus solely on pain.
“Pain is neither a necessary nor sufficient output of the stress response.”
Why should we limit ourselves to only treating pain? Why should we limit ourselves to only treating outputs? (Spoiler alert, we can’t treat outputs, change them) I have a better idea.
Today, I start treating a human system under threat.
The Threat Matrix
Dad showed me this great editorial here in which Eric Visser expands upon Melzack’s original pain neuromatrix.
Visser calls this idea the threat matrix. To simplify the idea, threatening inputs from the body and the environment enter the system, are scrutinized by the brain, and then the desired output to combat the threat occurs.
Input –> processing –> output
This framework explains how any output, desirable or undesirable, can occur from a stressful input.
Let’s apply this to an example that we have all been through; a breakup with a significant other.
Your significant other decides to leave you, how do you feel?
The answer depends on the individual. Some folks may feel depressed. Some may feel anger.
Some may even experience pain.
These feeling are all outputs that occur as a result from an input (i.e. the breakup) that disrupts homeostatic balance of the human system. The outputs that occur are the ones that the brain determines best aid the individual in recovery and survival.
Let’s now take this thought to the therapy realm. I sustain tissue damage and nociceptive information travels to the brain to be scrutinized. What output(s) could occur? Let’s think of a few possibilities.
Endocrine alterations in gut/reproductive function
Increased/decreased immune activity
Yada yada yada
All of these could occur, some of these could occur, or none of these could occur. The response to the offending input is going to depend on the individual’s brain scrutinizing the situation.
One could argue that a nociceptive event could lead to someone developing anxiety and poor immune function without ever experiencing pain if that is what the system feels best aids in survival.
Nonspecific Effects my Arse
There are many treatments out there that people deem worthless because research demonstrates minimal effects on pain compared to placebo. If someone gets better with this intervention, we deem that nonspecific effects led to the change in pain.
I call bullpoop…sort of.
Nonspecific effects could be a contributing factor to someone benefitting from a particular treatment, but the problem with most pain research is that often pain level is the only thing that is measured.
If pain is only one possible output of a system under threat, how do we know that a treatment didn’t affect a different output?
Answer: We don’t because it wasn’t measured!
Let’s take a controversial treatment for example: dry needling.
Some say it works wonders for pain, some are vehemently opposed, and research is mostly mixed. What do we do?
Perhaps both camps are wrong. Why? Pain is the only output being discussed.
What if this whole time, dry needling worked because it altered inputs coming in from the immune, autonomic, or [what the hell evahhhh] system, which led to changed output from this system primarily with pain output altered secondarily? And here is the kicker; the intervention only works if these systems respond as well as our pain system under a particular threat.
Well we don’t know that because we didn’t look at it. But looking at multiple systems when an intervention is implemented may give us more explanatory power as to why certain treatments help certain individuals. With this information, treatment could be streamlined and implemented.
Making pain our only concern to treat severely limit our capacity to help individuals. If we think of treating the stress response itself, we open up a huge realm of issues our interventions may affect.
If you take a look at the book “Spark” and the corresponding research, we see how exercise can alter many different outputs.
Why can’t rehab folks be a piece of this puzzle? It does not seem unreasonable to me that we could get referrals for anxiety, depression, or whatever output the stress response creates.
Strategically implemented exercise can help alter the stress response. That possibility makes me so hopeful for our professions.
How can one best assess a system under threat?
If clinicians are to assess if an individual is undergoing a chronic stress response, we need to find a reproducible methodology that gives us this information. We must look at the human system from the input/output standpoint.
There are several outputs that can be measured to assess an individual’s homeostatic state:
Other specific medical tests
These are all great tests that can assess the amount of system stress an individual is undertaking. That said, I feel there is an even simpler method of assessing the stress response:
Our physical examination
Assessing the stress response begins with the subjective examination. This piece of the clinician-patient interaction helps us assess potential offending inputs as well as individual processing.
If we come across red or yellow flags, we can easily refer out to providers who can deal with that piece of the stress response. Here is where a psychologist, surgeon, oncologist, other medical professional can come into play. These individuals can alter the offending inputs or help influence processing that therapists and the like may not be able to touch.
Let’s say we get through our subjective and we screen out that the above professionals do not need to be a part of this person’s care. Let us now proceed to our objective examination.
Assessing movement may be the simplest way to assess an individual’s stress status.
If we are to provide the “ideal” physical examination, we need to perform tests and measures that best differentiate a stressed from nonstressed individual.
To undertake this task, we need to have a few assumptions about what a nonstressed individual looks like. Let’s call this individual the “adaptable human.”
The adaptable human will have desirable multi-system variability. That is, human systems can perform as needed under certain situations without being “stuck” in a particular range. For example, blood pressure should stay lower when at rest and rise when performing physical activity. When blood pressure remains high at rest and with physical activity, that individual possesses system rigidity.
The adaptable human will have desirable multi-system capacity. That is, human systems can tolerate prolonged stressors without faltering. For example, a human can perform longer durations of physical activity with blood pressure remaining in levels that would not threaten one’s life.
The adaptable human will have desirable multi-system power. That is, human systems can tolerate intense stressors without faltering. For example, blood pressure can reach a desired level to allow for a particular physical activity to occur.
Our examinations ought to assess these three qualities: variability, capacity, and power.
Of the three, variability is most fundamental because almost every healthy human system functions in the manner. The movement system is no exception to this rule.
Movement variability, the ability to move in three planes, is the simplest reflection of this concept. A nonstressed system will possess movement variability. A stressed system shall become rigid and lose triplanar mobility.
Think to the last time you were stressed. Did your muscles tense or relax? As muscles tone increases, range of motion decreases. Assessing movement variability is an easy way to assess the general tone an individual has, and I speak more of why this notion is favorable here.
To assess variability, our examination must:
Look at the entire individual’s body
Cannot have bias toward one output (e.g. pain)
Must be reproducible and predictable
First, let’s look at popular rehab systems that I feel would not work in this instance and why.
Maitland: Biased toward altering one output (pain); segmental in nature.
McKenzie: Biased toward altering one output (pain); segmental in nature.
SFMA: Not necessarily biased toward one output, but does not look at entirety of human movement. Only two movement planes are assessed. Cannot see if an individual has variability in the frontal plane.
DNS: Wait? Do they even assess?
I shall let my bias now creep in as I suggest the current best model we have for movement variability is PRI.
There are several reasons why I think PRI is currently the best model to assess threat:
It is not biased toward altering one output, as movement rigidity can occur along with several other outputs besides pain.
The entire human movement system is assessed in three planes.
The protective patterns one undergoes in threat are predictable and similar for all individuals.
When one deviates from these patterns, likely pathology had to be created in order to do so.
If an individual can produce nonpathological triplanar movement throughout his or her body, then movement variability is present. A movement system under threat will not have this capacity. A threatened movement system will become rigid.
Establishing movement variability is our primary way to reduce threat-response outputs.
If undesirable outputs remain once movement variability is established, then we know other interventions must be given to address these areas.
If pain is still present, then previously mentioned assessment systems hold value, as does graded exposure.
This post is way over due, but a lot has been going on in life.
I have just moved to Arizona to start anew, and the change is bittersweet.
The Midwest is all that I have known for the past 27 years. I’m leaving a lot of loved ones behind that I will miss dearly.
However, getting out of the Midwest to a warmer place has always been a dream for me, and I finally got that opportunity. I also get to work at an awesome clinic alongside like-minded clinicians. One of my good friends will even be there.
Plus, summer forevaaaaaaaaaaaahhhhh!!!!!!
So with this transition in my life marks a good time to reflect on one of my many experiences at the Hruska Clinic. This time, I will show you how the clinic itself operates.
And their operation is a beautiful thing.
The General Feel
You walk in the door and can immediately shift into your left hip.
That’s what this place is like upon entering. With various shades of purple and tan, you just feel at ease being there.
It screams parasympathetic.
This build was no accident of course. Purple is a calming color, giving those at the clinic a huge home-field advantage. I bet there is also a reason why you walk left to check-in at the front desk.
The clinic is an interdisciplinary dream. The staff includes 5 physical therapists, an optometrist, a dentist, and a podiatrist. This setup allows for great communication among disciplines in order to provide the best individualized care for the patient at hand.
It was no big deal to call over the dentist to walk in and check out a patient during a session.
The physical therapists are where most people’s care starts. What is nice is they have several resources present to determine when to triage a patient to another provider. The clinicians had PRI glasses, orthotics, Asics shoes, mouth guards, and arch supports readily at their disposal.
Not everyone gets sent to another provider day 1 of course. Patients spend a few sessions working with one clinician, and if progress stalls then other options are undertaken.
A typical session at the clinic lasts 1 hour, and is all one-on-one care. Initial evaluations are very personalized to the patient, and much time is spent getting to know that individual. Not just from a physical therapy standpoint, but on a personal level. It was quite refreshing.
Objective examination consisted predominately of PRI testing, followed by large amount of education on pattern and position.
Most of the clinicians utilized various analogies to describe how PRI is performed. I heard various things ranging from car alignment, to wings on a plane, but what was emphasized with all these alignment-based analogies was that this position is normal. It is our position of comfort.
They also use the tests, and how quickly tests change, as educational pieces. The clinicians also liked showing natural asymmetries, such as the preference in which one crosses his or her arms, or the way one stands.
I personally would’ve like to see more pain neuroscience-based education, as you could see some patients start to get a little concerned regarding what was being told. The patient’s still got better of course, but anything to reduce threat perception is critical.
I can’t count how many times I’ve seen hip internal rotation measurements improve after a successful therapeutic neuroscience education session. Perhaps a PRI pain science affiliate course is in due order? 🙂
After education, the exercise program was implemented. Few exercises are given, but they are worked on for a large period of time. Form is to be impeccable by the end of the session. This work is needed since most patients are seen only once every one to two weeks. I love this frequency because the locus of control falls directly on the patient.
That’s pretty much the general clinic flow, and in my opinion it is the ideal treatment setup for patient success. The interdisciplinary care alone creates large variability in types of patients seen. Diagnoses I saw included pectus excavatum, “brain fog”, POTS, and chronic pain of all sorts. To me, that is the power of targeting the autonomic nervous system. You can affect any “diagnosis” that has an autonomic component; something PRI has a leg up on compared to most.
The remainder of this post is just going to include some various tips I picked up while there. The Hruska Clinic is definitely a neat place to see and worth the price of admission to observe (it cost $250/day to hang out).
I Have a Vision
You might be a vision patient if…
Have to reread pieces frequently.
You track with your finger (finger becomes a reference center to help your eyes track).
You have blurred vision.
I also got to observe a patient in PRI vision. It was a cool experience especially after going through it myself.
The patient had a 3-level cervical spine fusion with chronic neck and lower back pain. It was clear that the pain system was centrally sensitized, but what about the visual system?
As the patient walked, you could see minimal trunk rotation, large amounts of valgus collapse and pronation. Heidi, the resident optometrist, altered the patient’s lenses by 0.25 diopters. With that small change alone, the patient began walking with pelvic and trunk rotation, as well as decreased knee and foot collapse. She also reported less pain. So as we can see, the pain system is not the only system that becomes sensitized in chronic pain. Multiple systems, dare I say the individual, becomes sensitized.
“That’s a sensitive system.” ~Ron Hruska
It is possible that pain could increase with glasses on if tone is brought down low enough. The stability created by tone is taken away and control of new neurological space is not present. This is a threat to the system, which could lead to a pain experience in order to protect the patient.
PRI Vision Lite – Put reading glasses on someone and see if they let go. I personally have done this for several patients and it has worked wonders. I Had a woman who had shoulder pain, and I tried just about everything I could think of to alleviate her symptoms. No change. She puts on a pair of +1.0 reading glasses = no shoulder pain.
All Bite, no Bark
I generally have a hard time explaining how the stomatognathic system can play a role with various complaints, but one piece stood out to me quite well:
“If you have a piece of hair in your mouth, you can immediately feel it.”
This instance shows just how sensitive teeth can be. The stomatognathic system is neurologically-rich area for sensory input, and the trigeminal nerve has links to multiple body areas.
Other neat things I picked up:
Test patients by having them line up their three fingers in their mouth to rule out bite as a driver of position. This position allows the discs to rest.
On pulling teeth: If you are missing teeth you are missing a reference. So don’t pull if needed or neutral. Try to create room first. If that is not possible, then teeth must be pulled.
Testing Tips and Tricks
Watch how a shirt wrinkles when someone walks to see if trunk rotation is occurring.
If someone is sitting in bilateral hip internal rotation, the psoas is likely kicking in as an external rotator and pulling the spine forward.
During the Hruska adduction lift test, areas need to be felt. If you can’t feel something, then you need to inhibit something. Should feel at least 5/10 activity rating.
Nonmanual Tips and Tricks
For Exhaling – Think about the sigh you make when your mom and dad tell you to clean your room.
If someone gets excessive cramping with an activity, you need to inhibit something.
When performing a step up and over, reach forward with the right leg.
If the patient is having a hard time feeling the left IC adductor, go after the right intercostal.
If TFL or glute med kick in during an activity and the IC adductor is not felt, perform pure adduction activities with the knee and hip extended.
Manual Tips and Tricks
[Comparing manual to nonmanual techniques] – Left arm reach is equivalent to a left pec mobilization; right arm reach is equivalent to a subclavius release.
A good manual technique – Use your hands to create OA extension by providing a patient with a cervical lordosis. This is how I feel traction ought to be truly done. As when you perform traction (anyone still do that?), cervical lordosis is reduced.
“We don’t have proof, just a theory.”
“As your bite changes your vision is going to change.”
“Every time I touch my teeth I twist.”
“A balloon is theratube for your abs.”
“We don’t know.”
“If you’re not sleeping you’re not living.”
“All clenchers and grinders have no reference. Period. End of discussion.”
“I’m so sorry to make you do that.”
“The pattern doesn’t cause pain, but is an influence.”