Just when I thought I was out, the clinic pulls me back in.
Though I’m glad to be back. There’s just a different vibe, different pace, and ever-constant variety of challenges that being in the clinic simply provides. This has been especially true working in a rural area. You see a much wider variety, which challenges you to broaden your skillset.
Previously, I was all about getting people in and out of the door as quickly as possible; and with very few visits. I would cut them down to once a week or every other week damn-near immediately, and try to hit that three to five visit sweet spot.
This strategy no doubt worked, and people got better, but I had noticed I’d get repeat customers. Maybe it wasn’t the area that was initially hurting them, but they still were having trouble creep up. Or maybe it was the same pain, just taking much more activity to elicit the sensation.
It became clear that I was skipping steps to try and get my visit number low, when in reality I was doing a disservice to my patients. This was the equivalent of fast food PT—give them the protein, carbohydrates, and fats, forget about the vitamins and minerals.
Was getting someone out the door in 3 visits for me or for them? The younger, big ass ego me, wanted to known as the guy who got people better faster than everyone else. Yet the pursuit became detrimental to the patient’s best interest. There were so many other ways I could impact a patient’s overall health that I simply sacrificed in place of speed.
I only got them to survive without pushing them to thrive.
I see a lot of individuals proudly proclaim how many visits it takes for them to get someone out of pain, but pain relief is only part of the equation. There are so many more qualities we can address before we consider a rehab program a success.
This stark realization has reconceptualized how I structure a weekly rehab program. I now emphasize all qualities necessary to return to whatever task the patient desires, and attempt to inspire them beyond those initial goals.
You want to know what my visit average is right now?
I stopped counting, and started treating.
Let’s look designing the rehab week to take your clients to the next level.
Did you miss Movement Debrief live yesterday? Though much more fun live, I have a video of what we discussed below.
This debrief was quite fun, as we had an impromptu viewer q&a. Thank you Alan Luzietti for the awesome questions! If you follow along live on Facebook or Youtube, I will do my best to answer any questions you ask.
Yesterday we discussed the following topics:
Why you should emphasize sagittal plane activities longer than you think
How to coach exercises to maximize client learning and compliance
Why detaching from your client encounters makes you a better clinician
Viewer Q&A – “centering from the chaos” & TFL Inhibition
Lastly, if you want the acute:chronic workload calculator I spoke about, click here.
We are hosting several courses at my clinic this year, and we would love to have you, the readers, attend.
The three courses that East Valley Spine and Sports will be hosting are all excellent courses. I have taken two of these classes prior, and the third I have taken a prior rendition of. And let me tell you, these courses are boss.
Aside from us bringing some excellent content, you will also have the opportunity to hang out with a good group of people, and imbibe in some good beverages with me.
Here is what we are bringing.
PRI Pelvis Restoration: March 28th-29th
I took this course a little over a year ago (read the review here) and I am very excited to be learning from Lori again. She presents this very complex material in a systematic and understandable fashion.
ISPI Neurodynamics: The Bodies Living Alarm: October 17th-18th
I took a version of this class when Adriaan spoke for the NOI group, and I am excited to see what tweaks have been made since. This time we are bring Louie Puentedura in to teach the class. I am excited to hear his perspective, as I have never seen him talk. Adriaan speaks highly of him, so he’s okay in my book!
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.
One of the many reasons I was drawn to make the trek to Lincoln was to experience my man James Anderson’s original affiliate course.
I always enjoy hearing James’ perspective on PRI, and he did not disappoint here.
The course felt like an Impingement and Instability with a bias towards the geriatric/chronic pain populations. Some might argue that James is the king at implementing PRI here.
I really admired James saying throughout the course that the Geriatric population houses his favorite athletes, and they really are. High performance at any task, be it sprinting 100 meters or walking to pick up the mail, require similar alternating and reciprocal components. We still go after the same pieces to achieve different goals along a continuum.
So let’s dive into this high performance course for some high performing individuals.
PRI 101…or at Least the Pieces You Didn’t Get from My Other Reads
The affiliate courses have a huge introduction that gives an overview of PRI principles, namely the Left AIC and Right BC patterns.
I’m not going to go through all the nitty gritty as this course did, but instead I’ll review concepts that James cleaned up for me. Think of this post as an in-depth FAQ.
The big keys you need to know about PRI if you haven’t already been reading my stuff.
We are asymmetrical in form and function.
Our respiratory and neurological lateralization drives us to being right-dominant individuals. We normally favor right-stance.
If we stay lateralized over time, it becomes much harder to break this pattern. We become neurologically rigid (credit the term to my boys Bill and Eric) and lose triplanar capacity to move.
The goal is to manage these asymmetries so we can establish alternating (what happens on one side the exact opposite occurs on the other) and reciprocal (a joint goes through the full range of motion in one plane) activity.
We achieve alternating reciprocal function through respiration. Breathing regulates and balances the nervous system, which PRI values as most important. Combined with knowledge of triplanar biomechanics, and we can see what PRI focuses on:
What the Hell is a ZOA?
The ZOA, or zone of apposition, is the portion of the diaphragm that is directly adjacent to the inner aspect of the lower rib cage.
As we fully exhale via concentric abdominal activity, the ribs go down and in. We establish a ZOA. As we inhale, the abdominals eccentrically maintain a ZOA. The ZOA allows the diaphragm to stay domed and function maximally for respiration.
Comparing right and left diaphragms, the right diaphragm is better predisposed for many reasons to have a better ZOA than the left. This dominance via the right diaphragm’s large crura pulls the lumbar spine to the right.
The left diaphragm is shortened and better able to act as a postural muscle; pulling the spine into extension; becoming an agonist to the paraspinals.
Ergo, we want to do what is possible to establish a ZOA on the left. This piece is foundational for transitioning into left stance.
Ok, so Right Diaphragm is King. What else Lateralizes Us?
The triangularis sterni/transverse thoracis is built to combat left chest wall hyperinflation. Its fibers on the left side extend up to the second rib, which is one rib higher than on the right. Since this muscle is a powerful exhaler, this asymmetry helps promote greater exhalation from the left chest wall.
The other obvious asymmetry includes the lungs. The right lung has three lobes, and the left two. Aside from the right mediastinum containing less stuff, these lobes helps maximize alveolar air exchange when the pressure gradient is adequate for right chest wall airflow. The left chest wall easily pulls in air, so only two lobes are necessary for adequate oxygenation.
Neutral Neutral Neutral. You say that all the time. What’s that?
Neutrality is a state of rest; a transitional zone.
Moving in and out of neutrality constitutes going from one end-range of motion into a transitional zone between the other end-range of motion. This transitional zone is where neutrality lies.
When we are in a neutral state, our body stops moving and attempts to rest. We need this state so static activities (e.g. sitting, sleeping) are performed without excessive tone. Finding this resting point better allows us to move out of this state during dynamic activity.
Neutrality reduces our normal right lateralized bias and maximizes capacity to move in three planes bilaterally.
“Neutrality is not a point on a map. It’s a parasympathetic state of being.” ~ James Anderson
Alternating and Reciprocal Stuff
As stated above, alternating activity is when what occurs on one side the exact opposite occurs on the other; reciprocal activity is a joint going through full range of motion.
However, an interesting concept was presented at this course that I haven’t thought about. Just because one a joint is in one position on one side doesn’t mean the opposite must occur on the other side.
Take this example. Let’s say that I am in right stance. My trunk would normal rotate to the left. What happens if I need to see something occurring to right while I am on my right leg?
Obviously these situations do occur. Therefore, alternating reciprocal activity constitutes that if I am on my right leg, my trunk could go right or left. I have options to have my body move in an ipsilateral or contralateral fashion.
Why Does Humeroglenoid (HG) Horizontal Abduction Test Thoracic Rotation, and Why does it Become Limited?
In the right brachial chain (RBC) pattern, the thorax begins to rotate to the left via left rib external rotation and right rib internal rotation. Due to this ribcage activity, the sternum is rotated to the right, and the left chest wall is hyperinflated.
The left pectoralis major is what would limit horizontal abduction in this case. The attachments for the pec include the sternum and the lateral lip of the bicipital groove. If the sternum rotates right, the pec elongates. The pec major is also an accessory inspiratory muscle, so it becomes neurologically active to attempt to draw air into the hyperinflated left chest wall.
Since the left abdominals are not in a position to create a ZOA, the pec is unopposed. Pec major tone limits horizontal abduction; thus signifying limited right thoracic rotation.
You Mean Someone Actually Talks about the Bilateral BC???
There is a case in which both sides of the thorax become extended, hyperinflated, and ribs become externally rotated. This state is known as the bilateral brachial chain (BBC).
This positions leads to both hemidiaphragms functioning as postural stabilizers more so than respiratory muscles.
Trunk rotation would not occur on either side, thus horizontal abduction would be positive on both sides.
A New way to think of tests
There were a couple seated tests that were introduced in this course, but one big key was talked about regarding all the PRI functional tests:
Do they feel the same on both sides?
In other words, if a muscle contraction is to be felt during a portion of the test, is the contraction an equal intensity on both sides. If both sides are not equal, that may affect the way you decide to grade your tests.
How be Dem Feets of Yours?
In the left AIC pattern, the left foot is in an everted and pronated position. Whereas the right foot is in a more inverted and supinated position.
If the right medial longitudinal arch and calcaneus do not have enough support, be it from tissue or footwear, the right arch and medial foot may collapse to reach the floor. This foot is not pronated however, but is pronating.
If the feet have gotten to the point in which this pattern cannot be overcome, supportive footwear may be indicated. The keys to a good shoe include:
Stable heel counter; both posteriorly and laterally.
This footwear allows for calcaneal frontal plane control and supports the medial longitudinal arch. The inherent forefoot flexibility supports gait propulsive forces.
Having good shoewear can better allow the patient/client to find and feel areas necessary for alternating and reciprocal activity.
Your Habits, They Kinda Sorta Matter
Look at your stove. Tell me which burner is your favorite.
Did you choose the bottom right burner? Why is that one usually the largest? It fits a pattern of right-handed dominance. A pattern of right lateralization. It’s normal.
James pointed out many different habitual things that could influence one’s position. Think about where you like to be in some of these examples.
What side of the bed to do you sleep on? If you like the right, you’ll reinforce the Left AIC/Right BC. If you like the left, you are either neutral or patho.
What side of the couch do you nap on? The right side is usually preferred; especially if lying on the right side. If you like the left side of the couch and face out, you likely have a patho thorax.
Which island in your kitchen do you like? Assuming equal cupboard space, you probably prefer the island left of the stove compared to the right. Left island allows for right reach
There were many other examples that demonstrated the way our lives influence our patterned behavior. Making people become aware of these tendencies, and showing strategies to affect these preferences could be a way to help one integrate alternating reciprocal activity throughout the day. I can envision teaching someone to cook on their left burner as their HEP.
“Patterns develop into preferences.” ~ James Anderson
Stretching doesn’t work because it doesn’t shut tone off. Tone is increased because stretch is a force that is thrown at the system. The system responds to this force by increasing tone.
Torsion = compression. Think the lower back.
In the Hruska Adduction lift test, the bottom leg is looking at stance phase, the top leg looks at swing phase of gait.
In the Hruska Abduction lift test, the top leg is in swing phase, the bottom leg is in stance phase.
When treating someone, go after the most limited snowball (sacrum, sternum, sphenoid).
Home Integration Exercises
James gave many examples of what exercises might be beneficial for different situations (bed mobility, transfers, gait, etc). There were several neat exercise variations he introduced. I’ll show you some of my favorites.
This first activity helps establish a ZOA while rotating the trunk to the right. An easy way to slowly expose a right lateralized system to the left.
A neat trick when sitting is to press the back of your leg into an object to get left hamstring.
Also really loved how flexing the hip isometrically into a table intensified everything in this left stance exercise.
James also gave us several little tips and tricks to help improve exercise performance:
Use several pillows to flex the patient and achieve a better ZOA.
Use toilet paper rolls to create isometric adduction.
Use paper towel rolls if one must move his or her hips during an activity; these roll better than toilet paper for example.
I can’t say one bad thing about this course. In fact I’d say I got more out of this course than I thought I would. This was the best overview of PRI that I have witnessed.
For newbies to PRI, you will get blasted with a lot of content, and it won’t be easy to digest the first time around. The manual is so well done though, that this course provides a great way to learn the most about PRI in the broad sense. You could most certainly start your PRI journey here.
For the vets, concepts will become better understood and you will get some great exercise variations.
So should you check out PRI Integration for the home?
Great James Quotes
“Recliners are the thing.”
“Geriatric clients are my favorite athletes.”
“Toilet paper rolls are neural integrators.”
“Treat patients how they feel inside.”
“That’s like influencing your mother.”
“The diaphragm is the core of your core.”
“The brain is amazing because it can adapt to anything.”
“All human beings are right-sided dominant in everything.
“If you are one step ahead of the crowd, you are a genius; if you are two steps ahead of the crowd you are a crackpot.”
“If you’re not domed, your toned.”
“People cannot rest themselves.”
“Do you know any stretch that says take 3 breaths, clap your hands, and smoke a cigarette that gives you 40 degrees of shoulder motion?”
[on PT school] “You are going to charge me this much and give me three sentences on breathing??!!? You should give me three months! You should be ashamed.”
“Don’t blog that.”
“If I have 45 degrees overall in a muu muu I’m good.”
“Nobody in that Medicare room knows anything about gait.”
“Rod Stewart was dancing? He’s probably on amphetamines but good for him!”
“We’ve got a before collapse party and an after collapse party and the minimalist shoe wear goes to the after collapse party.”
“Whoa! PRI does nothing.”
“The left pelvis is different from the right. Drink!”
“Just blow the dang balloon up.”
“Recliners shut off people.”
“In a grandma course, really?”
“Don’t shift if shifting is irrelevant. Reach.”
“The diaphragm is your prime mover of the spine.”
“Don’t train not sure.”
“There is no problem with the pattern. The problem is when you can’t flip the coin.”
“The Timed Up and Go Test aka the hurry up and fall test.”
It is hard to believe that I have already written my 50th post after starting this blog in February as a way to enhance both my learning and the learning of others.
This blog has allowed me to interact with a variety of different individuals that I otherwise would not have. And when people who I deeply respect say they admire what I have to say (or at least my version of what other people say), I am deeply humbled.
But I have had several cases in which people wondered if I do anything other than physical therapy and personal training (I do). One of my former mentors came up to me saying that she was worried about me because of how much I am into this.
These interactions have made me reflect on why I am reading, working, writing, and learning as much as I can. Thus, I have come to some conclusions as to what drives me to help others. And this drive, while not the norm that some of my peers are accustomed to, is far from wrong.
Others are Depending on You
When you work as a health professional, some people neglect the fact that your patients and clients trust their bodies with you. They put their confidence in your knowledge and skills to show them the path to bettering themselves.
When someone puts this amount of trust into me, the last thing I want to do is let them down.
So I am going to put my utmost effort into helping them meet their goals. We do this by giving them the best quality of care of course, but that also means consistent honing of knowledge and skills to provide them with your best.
All too often I see clinicians and trainers who have not picked up a book or journal article since school ended; going through the motions day after day. I feel sorry for their patients and clients, because they are the ones who ultimately suffer. Patient care is just like maintaining a relationship with someone. If you do not put in the effort to better the relationship, it will eventually fail.
The worst thing you can do is mail it in day after day.
I Still Fail
Even though in the past year alone I feel I have improved my clinical understanding tremendously, I still have patients that do not get better. More than I would like…which is 0 🙂
Granted, there exists a certain sub-population of people who will just not get better regardless. But I am sure we all have patients that we think could have benefited from our services that did not.
Maybe you didn’t know what you were looking for…Then improve your assessment skills and learn better principles.
Maybe you weren’t familiar enough with their presentation…Then increase your knowledge base so you are familiar.
Maybe you didn’t have the right sensory input to apply to this person…Then learn new exercises and manual skills so you have the right inputs.
Maybe they didn’t follow through on their home program…Then improve your ability to motivate the next one to perform their exercises.
It is great if people do not improve due to something on our parts, because we then have the capacity to change these issues.
If you Pubmed search the keyword physical therapy, you will get 209444 hits (as of 8/22/13). No doubt if you check that phrase 2 months from now that number will increase. That is a lot of information, and new science comes out daily. By necessity, you have to keep up…especially if you want to know everything…which I don’t.
I think my wise mentor Bill Hartman put it best, “If you are not getting better, you are getting worse.”
It’s Damn Fun
The more that I read the more fascinated I become with what we do as clinicians and trainers. Especially since I have delved deeper into neurological topics, my approach and thought process has undergone a huge transformation. Gone are the biophysical thought processes in favor of a more biopsychosocial rationale. No longer am I telling patients that their facet joints are causing their pain. Now I say pain is the brain’s response to threat, and I am here to help turn down the defense mechanisms that go along with that.
To me, there is nothing more interesting and fun than going through and learning things that drastically change the way you think.
These areas are what keep me and this website going. Will I be writing summaries forever? Who knows? Maybe someday I will have an original thought. But I will say that as long as the passion stays, I and I hope you too will press on and continue to learn. When you stop learning, then it is time to hang it up.
What motivates you to learn? Please comment below.