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.
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!
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.
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.
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.
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.
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.”
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?
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:
What courses should I look at?
Any advice for a new grad?
Seriously, Bane. What’s the deal?
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.
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:
Symptoms after prolonged or unusual postures.
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.
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.
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.
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.
Breathing will become faster and shallower. Take a look at the diaphragm. Which side is larger?
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.
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…
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.
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.