If you missed me live, you can check out Episode 4 of Movement Debrief below. We hit a small technical difficulty early on, but it all ended up working out.
We discuss the following concepts:
Why I Emphasize Hamstrings before quadriceps after ACL reconstruction
Why Hip Rotation isn’t always a reliable measure
Interpreting the Ober’s Test
Meeting the Patient’s Needs vs the Clinician’s Needs
I apologize that the quality is not so great. I’ve moved to a rural part of Arizona, which as of right now does not allow for the best of streaming. If you friend me on facebook, however, you can watch the live stream, which has surprisingly much better quality.
Click here for the post I mentioned discussing combining blood flow restriction training with E-stim.
You shed that mindset with the game on the line. You must do all in your power to get that player back on the court tonight, expediting the return process to the nth degree.
I had a problem.
Figuring out the most efficient way to treat an ankle sprain was needed to help our team succeed. I searched the literature, therapeutic outskirts, and tinkered in order to devise an effective protocol.
The result? We had 12 ankle sprains this past season. After performing the protocol, eight were able to return and finish out the game. Out of the remaining four, three returned to full play in two days. The last guy? He was released two days after his last game.
It’s a tough business.
The best part was we had no re-sprains. An impressive feat considering the 80% recurrence rate¹. Caveats aside, treating acute injuries with an aggressive mindset can be immensely effective.
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.
Note: I made some errors on the first rendition of this blog that were corrected after speaking with Eric Oetter. Courtesy to him, Lori Thomsen, and Ron Hruska for cleaning up some concepts.
Four Months Later
When the Lori Thomsen says to come to Cervical Revolution, you kinda have to listen.
I was slightly hesitant to attend since I had taken this course back in January. I mean, it was only the 3rd course rendition. How much could have changed?
Holy schnikes! It is simply amazing what four months of polishing can do. It was as though I attended a completely different course. Did I get it all figured out? No. But the clarity gained this weekend left me feeling a lot better about this very complex material.
This is a course that will only continue to get better with time; if you have a chance to attend please do.
Let’s now have a moment of clarity.
The craniocervical region is the most mobile section of the vertebral column.
This mobility allows regional sensorimotor receptors to provide the brain accurate information on occipital position and movement.
The neck moves with particular biomechanics. Fryette’s laws suggest that the cervical spine produces ipsilateral spinal coupling in rotation and sidebending. The OA joint, on the other hand, couples contralaterally.
C2 is the regulator of cervical spine motion; much like the first rib regulates rib cage movement.
C2 is also important for the mandible, as it balances the cervical spine during mandibular opening. The reason this occurs is because the mandible and C2 are at the same fulcrum level.
Often triplanar motion will decrease amidst progressive respiratory demand or threat. These changes help promote neck stability while simultaneously increasing demand on the mandibular elevators, extraocular muscles, and vestibular system
If these changes occurs long enough, sensory issues may become prominent.
Stability can occur through increased sagittal plane activity in the upper cervical spine and cranium either one of two ways:
O on A via posterior cranial rotation
A on O via forward head posture
Both strategies attempt to flex the cranium, but both are undesirable if occurring underneath a lost cervical lordosis.
OA hyperflexion is often seen in those who sit in front of monitors for long periods of time. The visual system helps promote stability.
OA Hyperextension is an attempt to create an airway. Cranial protrusion may be utilized as a way to open up the airway under stable conditions. This position passively raises the hyoid bone, which often depresses when one uses a mouth-breathing strategy. These individuals rely heavily on the dentition for craniocervical awareness.
Of course, these are not the only ways undesirable neck stability can occur.
You might have a stable neck if:
You have a narrow palate.
You have a cross bite.
You have a narrow airway.
Patterned Mechanics 3037
The TMCC is the foundational polyarticular muscle chain at the neck, with the right side generally more active than the left.
The normal RTMCC pattern presents with the following at the neck:
C2-C7 orientation in the transverse and frontal plane to the right, with compensatory rotation and sidebending to the left.
The OA joint is sidebent to the right and rotated left as a passive orientation.
The RTMCC may be present in isolation or with various cranial strains.
A cranial strain may occur if the left SCM sidebends the OA left within the RTMCC pattern. This compensatory movement occurs to attempt to reduce OA rotation and upper cervical strain.
If you weren’t sleeping during the biomechanics section, you will notice that this goes against Fryette’s laws. In order for this compensatory strategy to occur, the right alar ligament and posterior capitis muscle must become lax. This movement does help reduce torsion and compression on the upper cervical segments, but may create a cranial lesion in the process.
This compensatory movement is a precursor to a left sidebending cranial lesion, and this lesion along with others are quite prominent.
According to a 2008 study by Timoshkin and Sandhouse, 72% of individuals have a cranium that is in a sidebend or torsion pattern; with left sidebend and right torsion being the most common.
Of those two cranial strains, the left sidebend will be the most common. Let’s dive into that pattern more.
Left sidebend (LSB)
The LSB lesion is named for the sphenoid’s greater wing position. In this case, the greater wing is high on the right and low on the left. The occiput matches this orientation.
Where these bones will differ occurs about a vertical axis; as the sphenoid externally rotates while the occiput internally rotates.
The mechanical change at the atlas drives this position. The sphenoid just goes along for the ride.
A prime example of this cranial strain would be the lovely Garey Busey.
Right Torsion (RT)
RT’s also have a low left greater wing of the sphenoid, but the big difference is at the sphenobasilar joint.
Since the RT is a progression from the LSB, the occiput will attempt to sidebend right to level occipital position. Since the sphenoid stays in position, torsion through the sphenobasilar joint occurs.
This twist is driven by the sphenoid as means to create pseudo-facial symmetry via extension.
Lorimer Moseley is actually a perfect example of this type of cranial position, as many facial features are flipped from a LSB face.
This is a Test
The only way to truly determine which cranial strain one has is through imaging, but PRI testing can guide us down a treatment path.
Admittedly, the cervical tests are not the most reliable of the PRI bunch. To attempt to offset this limitation, we shall imply a test battery to determine position.
There are four essential tests in the TMCC algorithm:
Cervical extension: Checks cervical lordosis presence; goal is 30-35 degrees.
If limitations are present it is likely that SCM hyperactivity is reducing the normal lordotic curve.
I think of this test as the extension drop test of the cranium. It tells you if you are working with someone who is sagittally lax or not.
Cervical axial rotation: Checking C7-T1 rotation, which reflects C2 position. Looking for symmetry at about 30-35 degrees of movement. This test determines the TMCC pattern.
Limitations will be present due to the cervical spine’s compensatory rotation and sidebend to the left. Placing the patient supine on a table rotates the spine further to the left, which places a RTMCC patterned neck in an end-range position. Hence, normally left cervical axial rotation is limited. We would see bilateral limitations in a BTMCC.
When performing this test you want to make sure that you do not give the patient a lordosis, for this can create false negatives.
Midcervical sidebending: I think of this test as the great comparer between the cervical spine and the cranium. Looking for symmetry at about 30-35 degrees. This test gives you a frame of reference for our next test.
In the RTMCC pattern, this test is limited to the right secondary to an arthrokinematic block. If the cervical spine is rotated left on the table, the neck cannot sidebend to the right. That’s Fryette’s laws brah!
OA sidebending: This test looks at cranial position. Looking for 8-10 degrees bilaterally.
More than 10 degrees of sidebending would indicate alar ligamentous laxity.
A RTMCC individual would have limited right OA sidebending due to a bony block. In someone with a LSB however, you would have limited L OA sidebending because the left SCM pulls the OA over to the left. A RT could present with just about anything, as pathology is quite prominent in these folks.
RTMCC repositioning and retraining goes about the following progression:
Cervical spine → OA joint → Mandible
The neck is the top priority because its mobility maximizes cranial sensory activity.
Moreover, most cranial activities are integrated multi-joint movements. Spending time doing “basic” PRI sets the foundation for one to combine complex movements.
Mandibular movement is often normalized by the time the neck is cleared. The reason TMJ mobility may be limited because of craniomandibular discord.
In the RTMCC pattern, the right lateral pterygoid works with the right anterior capitis and right SCM to deviate the temporal bone and mandible to the left whilst the occiput (and sphenoid) are “stuck” in the left sidebend position. In a neutral system, we would expect the occiput and sphenoid to move to the right during this cranial movement. This tonal issue could limit mandibular movement.
Thus, a neutral cranium often restores normal TMJ mechanics. If problems still arise, then mandibular re-education may be necessary.
Sometimes you need a Dentist
Of the two common cranial strains, RTs will most likely need integration.
With normal occlusion, one side of teeth should touch while the other discludes. This alternation creates lateral shifting in both the mandible and the cranium.
The canine teeth act as guides for where the jaw ought to be in space. When canines touch during shifting, molar contact follows as the teeth drop into position. This action is called group function.
If group function cannot occur, it is likely that a dentist may need to be involved.
Splint therapy is generally recommended in these cases. More specifically, mandibular splints are the go-to (which I spoke about here and here).
Maxillary splints are generally the devil. These splints tend to increase tongue activity and mandibular clenching to hold the splint in. The one major case that may warrant a maxillary splint is the presence of tori.
Even if not using PRI splints, there are four essential pieces needed from a dentist:
Don’t lock the mouth into a position.
Move head back and jaw forward with canines.
Feel one side occlude while the other side discludes.
Have group function and anterior guidance between incisors.
Note – anterior guidance is when the incisors touch the molars disclude
You might be wondering how I educate people about this stuff in a nonthreatening fashion. I got this neat little tidbit from the Ronimal:
“Periodontal ligaments are so sensitive that a hair will throw off your gait.” ~ Ron Hruska
Think about that statement the next time you get something stuck in your teeth. Drives you crazy right? If there is something undesirable going on with your teeth, you will know about it in some way. Some output will occur.
Moreover, think about what occurs at the dentition when stressed. Do you clench? Reducing this muscle over activity by splint therapy introduces a salient stimulus that could reduce the stress response, if the craniocervical region is involved.
Hint: It usually is.
Infamous Ron Quotes
“Every single bunion and ACL patient is a TMD patient.”
“I love dentistry, but I don’t like dentistry, but I like dentistry.”
“You cannot treat a neck if a neck can’t treat itself.”
“We are a product of how we move our cranium.”
“A bra strap will really mess a tongue up.”
“The worst thing you can do to a patient is splint their neck.”
“We still have a lot of goniometric minds.”
“What good is the polyvagal theory if you don’t understand the neck.”
“Don Neumann is the best book for 1% of the population.”
“Treatment starts when you appreciate frontal plane.”
“How can you treat a TMJ if you can’t control the T?”
“The vehicle you drive is not the problem, it’s the path your on.”
“A twisted levator is an untwisted neck.”
“Hallelujah you have a pattern.”
“When you lose your left ab wall the head and neck will pick up the slack.”
“You can learn a lot about cognition and personality if you look at a neck.”
“You can’t feel CSF flow if you lack a cervical lordosis.”
“Make sense out of sense.”
“A neck that can’t move will produce a cant.”
“Crossbites, pulled bicuspids, and high arches scare me.”
“Sedentary lifestyle and screens demand we go straight.”
I shipped off to Boston to attend my first ever BSMPG summer symposium. And it was easily one of the best conferences I’ve ever been to. There was an excellent speaker lineup and so much of my family. Art Horne really put on a fantastic show.
If you haven’t been to BSMPG before, put it on your to-course list. It is one of the few courses that has a perfect combination of learning and socializing. I hope to not miss another.
Instead of my usual this person talked about that, let’s look at some of the big pearls from the weekend.
Why Sapolsky Doesn’t Get Ulcers
In one quote Robert Sapolsky summed up my current foundational premise to rehabilitation and training:
“The stress response returns the body to homeostasis after actual or potential threats.” ~ Robert Sapolsky
Regardless of what your malady is, it can probably be linked back to the stress response gone awry. The specifics become irrelevant because the stress response occurs nonspecifically.
This response works best against acute crises. Guess how we screw it up? Chronic stressors.
Human stressors are quite different from other species’ as we have the capability of inducing this stress response psychosocially. Gazelles on the Serengeti don’t have to worry about student loans.
We can see how chronic stress becomes an issue when you look at what occurs in the stress response:
Glucose travels to the bloodstream to mobilize energy.
Increased cardiovascular tone, heart rate, and blood pressure.
Decrease long-term building projects such as digestion, growth, and reproduction.
Increase immune system activity
Sharpen cognition, alertness, and pleasure
If the stress response perpetuates, other systems fail and break down to continue to support the need to reduce potential threats. We see a shift in the homeostatic set-point toward elevated levels of the above.
Although we all must deal with stress in some way, why is it that some people tolerate chronic stress better than others? It’s all in how one copes. The following is needed to successfully deal with stress:
Aka good training. But how do we build up individuals to continually better tolerate further challenging stressors?
Here is where my man Eric Oetter dominated the conference.
When chronically stressed, the aforementioned stress response takes high priority in all our systems, including nervous. Immune molecules smudge our various homunculi, dopamine floods the system to reward outputs, and myelin solidifies neurological pathways to perpetuate it.
Breaking a chronic stress cycle involves habit alteration.
To be able to effectively create newly favorable habits, movements, or pathways, attention is key. This piece is something we lose in a stressed state; as prefrontal cortex activity decreases. This is why salience is so important.
To return to a favorable homeostatic environment, we enlist Eric’s three P’s:
Prime brain activity via the aerobic system. It boosts brain power, especially if done before an activity.
How: Work between 120-150 bpm for 15-30 minutes prior to motor skill learning. Do something you enjoy so you do not become overly stressed by the activity itself.
Sleep is a big deal. According to one of the speakers, Vincent Walsh, we sleep 37% of our lives. Yet we only work 19% of them. We sleep so damn much that it should probably be taken seriously.
Sleep helps us remember by helping us forget things. The sleep cycle replays our day; keeping the important pieces and discarding the unnecessary.
This discarding is the pruning that Eric referred to, and it occurs by glial cells. Glia is what smooths out new neural connections.
How do we get good sleep?
Respect the chronotype – keep your normal sleep-wake cycles.
Take naps – 26 minute naps are bomb.
Banish blue light – cut out 1-2 hours before bed, as blue light from electronics tells the suprachiastmatic nucleus in the brain that it is light out.
Become a sleep environmentalist – No caffeine after 12, no meals 3 hours before bed, sleep in a cool room, etc.
If you can’t access to the prefrontal cortex, you will never hit the cognitive stage of motor learning.
Chronic stressors inhibit access to the PFC. The PFC is the doorway to variability, which is something unwanted during a stress response. Automaticity is king.
Getting the PFC allows all systems to be freely expressed. How do we do it?
Monitoring (omegawave, bioforce HRV, etc).
Remove the “neurolock” via redirection and respiration (hint hint– PRI)
Energy systems development.
Respect the Thorax
This section will channel my homie’s James Anderson and Allen Gruver. Can’t go a place without getting a PRI fix.
What keeps the spine and sternum oriented right despite the thorax counter-rotating to the left? The answer would be airflow. A hyperinflated left chest wall pushes these areas to the right.
Thoracic movement is determined by this position as well as timing/coordination of gross movement patterns. We can observe how the thorax is driven through what the extremities are doing.
If you look at the baseball throw, we ought to see alternate positioning on each arm. For example, if the right forearm is in supination during a part of the throw, the left arm ought to be in pronation. This reciprocal arm function promote the thorax rotating in one direction. It’s a PNF thing.
If the arms go in the same direction, the thorax must extend or flex. Since sport is usually extension-driven, we can guess which direction one will go.
Vince Walsh gave an excellent talk on the brain. He thinks we miss lots of talent because we look predominately at physical prowess.
Physicality is only one piece of the puzzle. Some individuals may develop excellent decision-making skills later on in their careers that may trounce athleticism.
Your ability to make right choices and avoid wrong ones is necessary for success, and is a trainable skill.
To know how to train it, it is important to understand the three types of decision-making:
Physical – What to do and not do (e.g. gun slinging)
Mental – e.g. poker playing
Temporal – e.g. playing chicken
Vince predominately used computer simulations to train these decisions, but it seems plausible that these tests could be applied to any type of training. Perhaps something like a reactive agility test could help improve physical decision making as an example. You just have to be creative.
A Cautionary Note on Data
Al Smith said some of the most profound words this weekend. He spoke to caution us on data.
Data does not always tell the individual story, as it can lead to less individualized training or rehab. It dehumanizes both our clients and us. This statement made me think quite a bit to those folks who champion evidenced-based everything.
Perhaps instead of measuring everything, one must first ask if there is a problem with what one is thinking of measuring.
Another cool thing Al Smith showed us was the cynefin framework; a sense making model in which acquired data precedes framework.
Depending on what a situation can be categorized in, one would expect to utilize different thought processes.
Simple – predictable relationship between cause and effect (use best practice)
Complicated – predictable relationship between cause and effect that’s not self-evident (use good practice)
Complex – A system without causality (use safe-fail experiments)
Chaotic – A completely unpredictable system (Use novel practice)
Where does training fit? Where does rehab fit? We may be using incorrect methods in particular situations.
You can learn more about the framework here, it’s definitely something I hope to explore more in the future.
“Too much exercise is not normal hominid behavior.”
“This CT scan was not drawn by a commissioned artist.”
“If you think that’s a tight pec you better check pressure in the air.”
“10,000 hours can’t always undo 100 dumb ones.”
“Frank Netter shut down the left AIC.”
“Deny PNF and you are messing with the system.”
“We’re all barking down the same tree. We just like to complain.”
“No plan survives the first contact with the enemy.”
“Changing the answer is evolution; changing the question is revolution.”
“If you live in mediocrity you eventually think it’s good. You don’t know what good is.”