Movement Debrief Episode 1: Meet the Patient at Their Story

A Live Movement Video Series

Hey party people.

I recently started doing some live feeds on the interwebz. You can check me out on Facebook and Youtube if you want to see me live.

Otherwise, I thought I’d share with the very first episode of “Movement Debrief.”

 

Here we dive into the following topics:

  1. The importance of reflection
  2. Using similar language to the patient.
  3. De-threatening that language
  4. Restoring sagittal plane control
  5. A case for manual therapy

Enjoy!

 

Come Hang With Me: Courses At My Clinic

Dear Readership

 We are hosting several courses at my clinic this year, and we would love to have you, the readers, attend.

We...The readership
We…The readers

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.

Class is next, the course is nice, and we can talk neuro all night.
Class is next, the course is nice, and we can talk neuro all night.

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.

Most importantly, she’s funny!

Thank you, she'll be here two days.
Thank you, she’ll be here two days.

Signup for the course here.

ISPI Therapeutic Neuroscience Education: Educating Patients about Pain: June 6th-7th

Adriaan Louw is one of the best speakers I have heard, and the material is priceless (read my review here).

10% chance Adriaan will wear this outfit at the course. 100% chance the class will be stellar.
10% chance Adriaan will wear this outfit at the course. 100% chance the class will be stellar.

This course gives several practical insights as well as easy-to-learn neuroscience education that will help you become adept and educating patients on pain.

Signup for the course here.

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!

And it's not an easy read.
And it’s not an easy read.

Signup for the course here.

 

We look forward to seeing you. Come learn, laugh, and party with us in lovely AZ.

The Post Wonderful Time of the Year: 2014 Edition

And That’s a Wrap

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

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

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

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

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

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

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

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

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

8. Treatment at the Hruska Clinic: Initial Evaluation

Producing so much saliva
Producing so much saliva

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

7. Course Notes: PRI Postural Respiration

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

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

6. Course Notes: PRI Craniocervical Mandibular Restoration

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

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

5. The End of Pain

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

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

4. Course Notes: PRI Pelvis Restoration

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

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

3. Course Notes: Dermoneuromodulation

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

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

Fine by me.

2. Course Notes: Therapeutic Neuroscience Education

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

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

1. Course Notes: Explain Pain

A legend
A legend

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

Game Over!

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

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Pain Language and other Jive Talk

To All My Clinicians in the Struggle

It was all a dream, I used to read ortho magazines.
It was all a dream, I used to read ortho magazines.

 I struggle with patients.

Those patients that I am having trouble with are who I study the most. It’s that whole learning from your failures thing.

In studying these folks, I have noticed an interesting trend.

It doesn’t involve movement.

It doesn’t involve medical history

It doesn’t involve stress (though it always involve stress)

Instead it involves language. I have noticed a few commonalities in how those patients who are either not improving or have been in chronic pain for some time talk. There is one shift, however, that I notice more often than not.

Disembodiment from Your Sports Team

 I don’t really watch a whole lot of sports; I’d rather play them.  Sports fans however, interest me. It’s fascinating how much ownership a sports fan takes in his or her team.

Fascinating creatures indeed
Fascinating creatures indeed

This ownership is especially noticeable when things are going well.  Think of the language one may use during the following instances:

  • Huge victory – “We finally beat the Packers.”
  • Draft Picks – “Our team got some huge prospects.”
  • Championship win – “We are the champions….my friends.”

Notice though, how oftentimes language may shift when a team is not doing so well.

  • Huge loss – “The Bears lost…Again.”
  • Draft flops – “I can’t believe they chose Steve Urkel first round!.”
  • Championship loss – “They blew our chance of winning.”

Robert Cialdini discusses this concept in his book “Influence: The Psychology of Persuasion.” When our team is winning, we manipulate our association to said team to improve our self-image. On the flip-side, when our team is losing, we will do things to distance ourselves (you can read an interesting study on this here). Perhaps it switches from  “we win” to “they lost.” Or perhaps we wear team jerseys after a victory and regular clothes after a loss.

Or perhaps he's wondering why he'd determine a structure at fault, before considering it's the brain....Yes, this just happened. Gratefully accepted by Bill Hartman, I did need it.
Or perhaps he’s wondering why he’d determine a structure at fault, before considering it’s the brain….Yes, this just happened. Gratefully accepted by Bill Hartman, I did need it.

This same concept seems to apply to pain states. Think about those folks in acute pain/injuries:

  • My neck hurts.”
  • “I tore my ACL.”

Compared to those who perhaps are in more chronic pain states, or at least those folks who I have noticed are not doing well.

  • “It hurts in the neck.”
  • “It must be that bulging disc.”
  • “I have the neuropathy.”

The former examples still have ownership with their problem, while the latter distances themselves. They become disembodied from the perceived affected area.

They lose the area’s image. They no longer love their team. That shoulder jersey they used to wear stays in the closet.

What the zaccupples.com team jersey is.
What the zaccupples.com team jersey would be if the skeleton was actually asymmetrical.

I’m going to quit using my arm.

I’m going the start calling my arm “the” arm.

I’m going to start saying the arm is killing me (to which I ask the patient if I should call the cops).

I’m going to persist in a chronic pain cycle.

 What to Do What to Do

 A patient’s descriptors and metaphors can play a critical role in how the pain experience is perceived. If thoughts and beliefs are what seem to impair one’s function, then it is those impairments that must be addressed.

Your goal is to get the patient to fall in love with the affected area again.

In order to play neurological cupid, shifting a patient’s language can have profound effects. It may be as simple as just making them aware of how they are describing the affected body region; relating these descriptors to brain smudging. You could also use the sports fan example above:

“Your perception of pain has led you to become a disgruntled fan of your shoulder. You need you [notice how I frame the needs to what they need to improve] to become a super fan of your shoulder again. It is your shoulder; take ownership in it. I’m going to show you some gentle exercises that will give you that winning streak you need to start cheering for your team again.”

This will happen in your educational conquest I can promise you that.
This will happen in your educational conquest I can promise you that.

Regardless of what direction you choose to go, you have to do all that is possible to change your patient’s perceptions, thoughts, beliefs, and fears regarding the pain experience.

It’s one of the hardest things we have to do.

What are some of your tips, tricks, phrases you notice?

New magazine I may start??
New magazine I may start??

PRI and Pain Science: Yes You Can Do It

Questions

You may have noticed that my blogging frequency has been a little slower than the usual, and I would like to apologize for that. I am in the midst of creating my first course that I am presenting to my coworkers. It has been a very exciting yet time-consuming process. It makes me excited and more motivated to someday start teaching more on the reg.

Ever since I started blogging people started asking me questions. These range from many topics regarding physical therapy, career advice, and the like. Some of the more frequent ones include:

  1. What courses should I look at?
  2. Any advice for a new grad?
  3. Seriously, Bane. What’s the deal?
Some questions are best left unanswered.
Some questions are best left unanswered brother.

But the one I get asked more often then not is as follows:

“Zac, how do you integrate PRI into a pain science model?”

A great question indeed, especially to those who are relatively unfamiliar with PRI. With all the HG, GH, AF, FA, and FU’s, it’s easy to get lost in the anatomical explanations.

Hell, the company even has the word (gasp) “posture” in the title. Surely they cannot think that posture and pain are correlated.

One of my favorite actors of all time. RIP
One of my favorite actors of all time. RIP

I think there is a lot of misinformation regarding PRI’s methodology and framework. What needs to be understood is that PRI is a systematic, biopsychosocial approach that predominately (though not exclusively) deals with the autonomic nervous system. The ANS is very much linked into pain states, though not a causative factor.

But of course, that may not be enough. Perhaps we can dig a little deeper into what may be going on. My hope with this blog is to make a guide to integrating two very effective paradigms which I feel are not mutually exclusive.

PRI Patterns and Nociception

 David Butler discusses many nociceptive processes, including mechanically-induced pain, inflammation, and ischemia.

I feel that the PRI patterns, albeit normal, could contribute to nociceptive processes. Mechanical pain makes the most sense. We could think of this process as typical anatomy/biomechanics. If one is in a right-lateralized and extended position, certain areas are going to be more prone to mechanical deformation than others.

Inflammatory processes could be caused by acute injuries secondary to position. The easiest example I could give would be an ankle sprain. If someone is in a right lateralized pattern (a la Left AIC), the right ankle/foot complex would be more supinated, thus being more at risk to sustain an ankle sprain. So in these cases, a right lateralized pattern could be one of many risk factors for leading to an injury.

Ischemic nociception is where things get interesting. There are two ischemic features that Butler mentions in “The Sensitive Nervous System” that stood out to me:

  1. Symptoms after prolonged or unusual postures.
  2. Rapid ease of symptoms after a change of posture.

If I am right lateralized and unable to leave right stance, this position could become ischemic after a prolonged period. Less movement, less axoplamsic activity, less blood flow.

You can't feel the flow when you can't move.
You can’t feel the flow when you can’t move.

Moreover, symptoms would be much more challenging to relieve. If I am unable to adduct and internally rotate my hip maximally, then I effectively limit what movement planes I am capable of utilizing. This concept is what Bill Hartman calls movement variability. When a position becomes nociceptive, movement must occur to reduce danger signals and restore axoplasmic and blood flow. I am looking for freedom. But triplanar activity is unachievable, movement freedom becomes a limited resource.

I simply lose the ability to change posture, which limits my ability to relieve ischemia.

 PRI Patterns and Peripheral Neuropathic Pain

 When I am in right or left stance, the nervous system slides and glides to accommodate position. Suppose I am in right stance. Right stance would require my right hip to be more extended, adducted, and internally rotated. My left hip would be flexed, abducted, and externally rotated.

When my hips are positioned as above, the sciatic nerve would be more taut on the right and slacked on the left. Now if I never leave right stance (aka left AIC), then I could potentially be more at risk for tension impairments on the right.

Another example would involve spinal position. Research demonstrates that humans have a naturally right oriented spine (here & here) which is precisely what PRI advocates. This orientation may bias more compression on the right nerve root than the left. If we have someone who presents with a dominant PEC i.e. spinal hyperextension, we could potentially see increased compression bilaterally.

Here we go yo, it's just a potential scenario.
Here we go yo, it’s just a potential scenario.

PRI, What a Great Defense

Now of course, we know very well that nociception and peripheral neuropathic issues are neither necessary nor sufficient for a pain experience. So how does PRI relate to pain?

Simple, the PRI patterns are the perfect protective postures for us to assume when we are threatened.

We drive these patterns via our autonomic nervous system. If you read Stephen Porges work, he discusses the concept of neuroception. Neuroception is how our nervous system’s evaluates risk. We take all sensory information in regarding our environment and determine if we should fight, flight, freeze, or relax and socialize.

When we neurocept (is that a word??) something as a threat, we will become more sympathetically driven and likely use our most efficient processes to respond to the threat. We use what we know.

Play Scrabble with me and you'll find I make up words all the time.
Play Scrabble with me and you’ll find I make up words all the time.

We bias ourselves to the right because motor planning occurs in the left hemisphere regardless of hand-dominance. If I stand on my right leg, I simply am better able to make my next move than if I were to stand on my left.

We will increase activity of our anti-gravity muscles, our extensors. To defend against a threat, it probably makes sense to stay upright. This function has governors present in the reticular formation. The pontine reticulospinal tract controls extensor tone, and the medullary reticulospinal tract inhibits this tone. One of these is spontaneously active and the other is not. Guess which one? Extension is the norm to keep upright. Thus, extensor tone is the brain’s reflex-driven path of least resistance. Perhaps if I am under threat long enough, I become a PEC?

Breathing will become faster and shallower. Take a look at the diaphragm. Which side is larger?

Would you look at that.
Would you look at that.

The right hemidiaphragm is larger and more powerful than the left. If I am already biased to the right and have a stronger muscle on the right, breathing becomes a less conscious process.

My point of listing these plausible changes in response to theat is to demonstrate that we are fairly similar creatures. Bill again, helped me realize this on a post he made at Somasimple.

If a lion were to walk in the room, what physiological changes would we undergo? Our heart rate would increase, pupils would dilate, HRV decreases, we sweat, etc. Are these responses not the same for all humans? These physiological changes are a common human pattern. Could it be possible there is a common threat response in postural and muscular activity as well? This pattern of positioning and neurological bias is what I feel PRI has put together more completely than anyone else.

Granted, we can still account for individual differences, but realize these changes are likely minor variations off the normal response.

When under threat, your heart rate increases 20 beats per minute, mine increases 10.

When under threat, your sweat accumulates on your brow, mine on my palms.

When under threat, your left anterior hip capsule becomes lax via compensatory external rotation, mine stays intact after compensatory external rotation.

Similar responses occur through varying degrees.

We're not so different, you and I.
We’re not so different, you and I.

Treating Pain Through PRI Approaches

I think PRI can influence the pain experience by altering autonomics via the vagus nerve. Paced breathing can positively influence pain states, and PRI breathing-style is very much paced.

The positions utilized are the farthest removed from the typical protective response when we perceive threat. If right stance with increased extension is what we do when we are threatened, then I am going to get you into left stance and flex you until the cows come home.

PRI essentially is graded exposure into left stance and parasympathetic paradise.

That doesn’t mean that PRI is going to eliminate the entire pain experience in all cases. There are some people who have injuries that are producing nociception, and may take time to heal. There are some people who have enough neural sensitivity requiring a hands-on or neurodynamic approach. There are some people who have centrally-maintained pain experience that requires graded exposure, pacing, and homuncular refreshments. The autonomic protective response is one piece of the puzzle, and altering that piece is the only way one can know if it is contributing to one’s complaint.

Therapeutic Neuroscience Education…PRI Style

So usually when I educate patients I just run through the above as quickly as possible…

download (2)

Okay that’s not 100% true.

I actually use the concept of a home security system to explain how PRI patterns are a part of the pain experience. Go ahead, watch the video, I’ll wait.

So as you can see, I do not go into nitty gritty detail of PRI methodology. It is mostly not necessary and could potentially increase threat perception. But framing the system as done above can help the patient understand why we may work at areas far away from the pain experience. We are treating what area of the system continues driving the protective response. We are treating the person.

In Summation

PRI is a very powerful system that does not have to go against current pain research, not that it ever did. But the above may be a potential framework and justification as to how PRI affects the pain experience.  It is the framework that I operate on, and will continue operating on until I am shown otherwise.

I hope that I am.

Who knows where the rabbit hole goes next.
Who knows where the rabbit hole goes next.