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Hello triplanar thinkers!

For those wondering, the picture is relevant because it shows a technique not often considered for the condition treated:  keeping a severed hand alive by grafting it to the patient’s ankle, then later replanting the hand back on his arm. 

The conclusion of my story about Don didn’t involve any external fixators, but the treatment that he needed might surprise some of you.  To review, Don was the patient with left shoulder bicipital tendinosis whom I treated in part I (link) with the “gold standard” conservative orthopedic approach and part II (link) with the according postoperative approach as a good therapist has been trained to.  As mentioned, I outline this case to review the path that is so very accepted and yet, in my experience since I began training with PRI, not the most effective.  Don’s story concludes below:

Don returned to clinic 8 months after discharge with a new diagnosis of left shoulder pain with the remarks on the script “MRI negative” and “eval and treat.”  This is generally understood as physician lingo for “I have no idea what to do now…good luck with all that.” 

Upon evaluation, Don reported that these left shoulder symptoms started about 2-3 months after we discharged him from PT intervention in spite of his persistence with his HEP and “it was all back to the starting point three months later.”  He still tested as a bilateral brachial chain patient with a PEC pattern, again was positive with impingement tests—Hawkins-kennedy, empty can, Neer sign.  He was frustrated, unable to work in his wood shop or play his accordion for more than 10 minutes without severe pain.  At this point, the patient and I discussed that fact that I had let him down to a degree because I wanted to take a different approach before surgery, but didn’t want to irritate Don or his referral source.  He understood, accepted my apology and we moved forward.

During the first 3 visits, we established that his bilateral brachial chain pattern and according left shoulder dysfunction was not the root of his dysfunction, but rather the manifestation of a “bottom up” pelvis patient whose primary difficulty was in maintaining frontal plane position of his pelvis. 

The key to Don’s left shoulder function?  Right posterior inlet inhibition of his pelvis.  During the seven visits we treated Don using a PRI approach after the gold standard of orthopedic medicine and orthopedic physical therapy had failed to maintain his shoulder function for more than 3 months, his symptoms resolved.  He left the clinic a reciprocal, alternating, smiling woodshop athlete with bilateral HADLT tests of 4/5 at 72 years of age, “tickled” that he could play his accordion as long as he wanted without pain for the first time since before he first went to see the doctor more than two years prior.  Don is in occasional contact for the past 6 months with no return of symptoms, lots of activity and happy thoughts. 

Six-month follow-up with no return of symptoms after the rest of my conservative clinical skills, an appropriate surgery and present day gold-standard postoperative care was unsuccessful.  These are the types of outcomes that keep my passion for this science alive and accelerating.  Moreover, these are the types of patient successes that remind me to be gentle but bold about intervention that I know clinically to be the most effective tool I have in the entire tool chest.

Clearly, each patient is different, and no, I have not seen a consistent correlation over time between the diagnosis of left shoulder bicipital tendinosis and the need for right posterior inlet inhibition.  The objective tests guided me to find the appropriate treatment, not my innate ability to hear the pelvis or shoulder speak to me. 

The point here is not to create a case study for anyone to memorize to use in the future for that one seemingly random patient.  Rather, I hope that the take home is that there is a chance that this gentleman didn’t need as much intervention as he ended up having.  And, even in the face of the “old school” telling you exactly what they want from PT intervention, the risk is worth the reward if one can just take the first three or four visits to break down barriers to a different way of approaching an age-old mechanical dysfunction of a “shoulder.”

Thank you for reading, perhaps you can save a few visits for a few of your patients by way of my experience with Don.   My best to you!

Jess

I have the benefit of being associated with some outstanding thinkers and PRI practitioners.  Whenever and wherever we get together, conversation eventually drifts toward discussion of PRI principles and application.  One of our greatest challenges has been to unravel the foundations from which Ron Hruska evolved the Postural Restoration Institute system of evaluation and treatment that we all utilize with such great success. 

The following are just a couple of questions that we have posed and our attempts to reach conclusions and greater understanding.  If anything it may stimulate some thought and initiate some discussion.

What are we actually measuring when we place a patient on the treatment table and perform our PRI testing algorithm and what is our goal for treatment?

I clearly recall a conversation over lunch between Eric Oetter, Mike Robertson, and myself during the PRI Pelvis Restoration course at the Cantrell Center for Physical Therapy and Wellness. We were discussing the concepts of adaptive capacity, adaptive potential, movement variability, what we are actually measuring when evaluating a patient on the treatment table, and how this affects performance.  

Our conclusion was that what we are actually measuring as PRI-educated therapists and coaches is the capacity of our client/athlete to adapt to the ever chaotic nature of the environment they are perceiving.  Positive findings during examination such as a positive Adduction Drop Test, limited apical expansion, or loss of shoulder rotation was merely indicative of a human system incapable of demonstrating variability ultimately controlled by the central nervous system.  More specifically an autonomic nervous system shift toward sympathetic dominance.

I was reminded of this PRI lunch after reading a blog post recently that referenced the following study:

http://www.ncbi.nlm.nih.gov/pubmed/24502841

In essence, what the researchers found in the study was that pain-free subjects demonstrated variability in the muscle activity of the erector spinae during a repetitive lifting task and those with low back pain did not demonstrate this variability as well as experiencing increased pain during the task.

The authors’ conclusion was that reduced variability of muscle activity may have important implications for the provocation and recurrence of LBP due to repetitive tasks.

Needless to say, this study is somewhat validating for our discussion group of PRI faithful.

Truth be told, after searching there are many studies that support our lunchtime conclusion; and movement variability as a favorable concept in human function is not a new concept having its foundations in dynamic systems theory. 

From Shumway-Cook and Woollacott’s Motor Control:  Translating Research into Clinical Practice:

“… in dynamic systems theory, variability is not considered to be the result of error, but rather as a necessary condition of optimal function.  Optimal variability provides for flexible, adaptive strategies, allowing adjustment to environmental change, and as such is a central feature of normal movement.”

What the PRI model provides is a non-invasive real-time measurement of system variability determined by autonomic nervous system tone.  While EEG, heart rate variability, or galvanic skin response may be preferred methods to determine autonomic tone, these are not tools commonly used by a practicing physical therapist in a clinical setting or a coach in the training room nor would they be practical. 

The goal of treatment then becomes restoring an optimal level of variability to the system to allow for optimization of behavior and maximization of performance.

We came up with a statement that encompassed our entire discussion that included the influence of variability on pain and performance.  I still have the notes on my iPhone dated 8/24/13: 

“Restoring variability to the human system is the ultimate goal to promote neuroplastic change creating a relatively permanent change in behavior that provides adaptability within the system to cope with variability in the environment.”

In PRI terms, our goal is help a patient achieve neutral (restore variability) and then recruit the appropriate PRI planar families (neuroplastic change to remap the three planes in the brain… Thanks to Zac Cupples!) to restore reciprocal and alternating movement (change behavior to cope with the environment).

How did Ron Hruska arrive at the concept of using simple, common orthopedic tests as effective PRI measurement tools?

As mentioned above, as physical therapists our measurement tools are limited by practicality.  If we look at PRI from a strictly biomechanical perspective, the PRI methodology provides for a low barrier of entry to a PT who has never been exposed to its concepts before.  Myokinematic Restoration looks, sounds, and feels like biomechanical course, but we all know that it is not.  This is a brilliant way to provide understanding to a group with more than a few preconceived notions, right?

While I certainly cannot speak for Ron, and I’m willing to be wrong, I believe there is more to this process, and this came from a conversation I had with Eric Oetter over Sunday breakfast.

From our first day in an introductory PRI course we are shown that asymmetry because of in-utero development and positioning, brain hemispheric dominance, asymmetrical vestibular development, and internal anatomical differences is normal, expected, and predictable.  Determining patterning that represents discord in the system then seems to be impossible until your realize that the skeletal system, is inherently symmetrical.  Therefore there is no better way for a physical therapist to determine the state of the system as a whole than identifying asymmetries or patterns via our typical orthopedic testing.

The brain processes and integrates all sensory inputs, internal and external, and generates behavior, including motor behavior, based on our perceptions with respect to the environment, emotional status, and previous experiences.  I don’t think it’s unreasonable to consider that the ability to produce reciprocal and alternating movement is not only an effective measure of autonomic tone but also a key measurement of overall health.

Bill Hartman, PT

“Its Monday Morning, I’ve just taken my first PRI course and now what do I do and where do I start?”

If you have just taken your first PRI course and you feel a bit overloaded with information, don’t feel alone.  The first time I went to a PRI course, can I tell you I was intrigued, stunned and just a bit intimidated all at the same time?  I didn’t know what the heck I was doing so on Monday morning I had a bunch of people blowing up balloons! (Take the Postural Respiration course and you will know what I mean!)

In fact, the entire body of knowledge of PRI can feel like one big elephant you are trying to digest.  And you know the old question, how do you eat an elephant?  One bite at a time!

The first thing to do is what you learn in every course and that is to breathe and relax. There is a lot information here that needs to sink in over time and you won’t get it all the first time. No one that has taken one of these courses has gotten it all the first time but if a door is opened to your curiosity and caring to learn more you are definitely on the right track!

What helped me in my overwhelm was to create a picture in my mind of some of the basics.  For instance, we aren’t symmetrical and never will be but the point is to manage asymmetries and get neutral. Then, have a simple picture anatomically of the basic asymmetries left and right side and how they affect position and posture thru polyarticular chains.  Remember how the diaphragm is the key player and you have a simple way to describe what you are doing to yourself, patients or clients.  They will be impressed by just a short, and I mean short, description of their anatomy and how it affects them.

On Monday morning, pick one person you feel comfortable with to experiment on.  If you have a colleague that has gone to a course practice with them.   Tell your patient that you just got out of a course and you want to try some powerful tools with them.    If you took a Myokinematics course, practice an abduction drop test and show them one basic exercise.  It is best that you practice that exercise yourself and continue to practice PRI tests and exercises yourself, so you know what it feels like and what to feel when you are in position for facilitation and inhibition.  PRI works best when we are managing our own asymmetries!

Immediately you have knowledge and application of assessment and corrective positioning that is really sophisticated and you have just scratched the surface.  You can build on this by learning a new assessment or two with a new corrective position every day.

Have your manual close.  Refer to it, study it and get a more detailed picture in your mind of how the human body works and how you can be more effective.  This is called building a body of knowledge and it doesn’t happen overnight but you can get results and get excited with just the basics and build on top of them.

If you went to a live seminar, order the home study course and review it a few times.  If you got a home course, go to a live course to interact with the instructor and fellow students.  Pack a bunch of questions in your bag when you go!  If you get a little frustrated with all the information and it doesn’t make sense all at once, then you are a normal human being!  Hang in there.  The good news is that becoming more skilled and competent is satisfying and meaningful and that building a body of knowledge and expanding what you know is just plain fun!   

To summarize part I for those who didn’t see it, I treated a gentleman with biceps tendinosis giving my best efforts to treat within the realm of what the patient and his physician expected.  He was pleased, reported 90% improvement and had met all but one of his functional goals—and I wasn’t content.  I wasn’t content because I hadn’t been bold/confident enough to risk the referral source by advocating for the patient like I had wanted to.  When things had a hitch, I had broached the subject of asymmetry several times, with a discussion of thorax and diaphragm position combined with respiration being key to arthrokinematics and myokinematics of the affected left shoulder briefly.  But the feedback each time was something of the “dang kids and their wide-eyed plans.”  So, I deferred to the ‘gold standard’ treatment of the day for said diagnosis outlined briefly in part I of this story with some PRI principles intertwined the best I could without the patient’s objection.

Three months later, Don arrived for this second round of PT with a diagnosis of left shoulder s/p arthroscopic subacromial decompression with a distal clavicle resection and biceps tenotomy.  His orders were specific to “ROM and strengthening” and he had a firm grip on what he wished to achieve per his physician’s orders.  Though I mentioned that, after the first couple of weeks, it would be wise to treat the cause rather than the symptoms of his left shoulder problem, he only agreed we’d reassess after a few weeks.

I saw him once a week for three weeks and he attained full ROM, felt wondersplendiferous (there is a small reward for whoever first tweets the three root words for this nonsensical term) and he was touting my praises loudly when he arrived at the fourth visit.  No pain, full motion, strong, highly functional at home and with hobbies.

Most of you reading this have been there.  We pray this patient maintains this status and we don’t want to be the bad-news “physical torturist” because sometimes they are functional for a long time this way.  Knowing his reluctance to work outside the realm of he and his surgeon’s normal, I stood down.  He had met all of his goals, he did have functional strength, motion and his goals were met.  I simply reminded him that I had done very little, that there was likely still a root cause of this now-recurring left shoulder dysfunction, not to feel hopeless if it did ever recur, wished him my best and discharged him—physician and patient goals met.  

For now.

I’m interested in your feedback, stories, predictions for part III, anything you'd like to add to this little story so far.  Again, this is outlining a classic case where the road less traveled is a bit risky, and in this case I took the easy way out with some objective data to support my decision. 

Part III coming soon…

Myokinematic Restoration originally scheduled in Spokane, WA, has been moved to Seattle, WA on May 31-June 1st! There are still a handful of seats available, so if you are in the Northwest, be sure to register soon. The early registration rate of $445 has been extended until next Wednesday, May 21st!

Check on the new recent email that has been posted, where James Anderson answers a course attendees questions on the FA Range of Motion charts in the Myokinematic Restoration course manual.

CLICK HERE to read Jame's response, and to check out all the recent email questions in the archives!

Check out this newly released article by Emily Soiney, titled “Taking Yoga to the Next Level-Postural Restoration-Inspired Yoga for the Athlete: The Frontal Plane”. Emily is also busy preparing for the first PRI Integration for Yoga affiliate course which will be held in Portland, OR on September 13-14th! Additional seats have just been opened for this course, so if you are interested in attending be sure to reserve your seat today. CLICK HERE to register!

Jen Poulin will be traveling with her husband, Chris to the UK this summer to share PRI overseas! Pro Sport Physiotherapy in York, England will be hosting Myokinematic Restoration on July 26-27, 2014. Physiotherapist Martin Higgins, along with fitness professional Kevin Duffy will be hosting the course, and space is limited! If you are interested in attending, be sure to sign up soon!

CLICK HERE to register for the course!

Don't miss the opportunity to take the Cervical-Cranio-Mandibular Restoration course taught by Ron Hruska in Richmond, VA on May 17-18th! The early registration deadline is this Friday, and we are still a few registrations short of confirming this course. If you are currently signed up, and want to help make sure this course doesn't get cancelled, phone a friend and invite them to attend the course with you.

CLICK HERE to sign up for the course!

Christy Peterson (PRC) and I gave a riding clinic April 6 and 7 at her facility (Riverside Physical Therapy) in Ord, Nebraska.  This was an ideal setting, because Christy’s facility is located on her farm which has an outdoor arena for riding.  Participants trailered their horses in from the surrounding area.  All were competitive riders (mix of Western and English disciplines), some of whom were competing at the World level.

After PRI evaluation and treatment, followed by some PRI-based exercises designed specifically for riders, each rider saddled up!  They were tasked with integrating what they learned off-horse to on-horse…challenging but powerfully effective.  Riders must be able to move their seat, arms/hands, and legs independently of each other in order to guide and lead the horse successfully and perform well.  This requires extraordinary body awareness, subtle controlled movements, and centering to the ground (not the horse) atop a powerful animal that has its own asymmetries.  Riding is a complex sport and often referred to as an artform.

It has been my experience over the past 3 years that many of the cues traditionally used by riding trainers are misinterpreted by riders and promote an extension pattern.  I cringe when I hear these particular cues:  “sit tall”, “chest up”, “shoulders back”.  Interestingly, a term that both Christy and I use to highlight and promote flexion for riders is the word “collection”.  Riders know and understand this term, because it is used to describe a state of posture and movement of the horse.  “Collection”: moving back to front; getting hind legs under the belly for powerful movement, balance, and control; top line of the horse lengthened and bottom line shortened.  So, when we get a rider into an All-Fours position, a 90-90 Hip Lift, or a Supported Standing Wall Reach and ask them to “collect”, they will instinctively reach their knees forward with a posterior tilt of the pelvis to “move from behind” and activate their hamstrings.  Pretty cool!  It is also a helpful cue for the seated posture of riders in their saddles…lumbopelvic flexion with the front of the hips open. 

Christy and I both learned from working with each other, and the participants seemed to appreciate the dual point of views.  We are in the process of planning more clinics, since we had such a positive response.  Each participant received an individualized 2-hour session with both Christy and I. 

I hope to extend these types of clinics across the country…beginning with NE, MD, VA, PA, NC.  If you are interested in hosting one of these types of clinics, please contact me at Lilla@MovementControlSpecialists.com or visit www.EmpoweredRider.com.

Posted by Lilla Marhefka (PRT).

Seattle, WA (Myokinematic Restoration) – “I had a blast in Everett, Washington this past weekend. Betsy and Zach are now PRC’s and that made me proud as I met Betsy when I was training to teach this course!  Zach provided excellent support as my lab assistant. The jet-lag was worth all the hole control and appreciation for integration of pattern and position.  This group was a mix of PRC’s, aspiring PRC’s, and some brand new to the science of PRI.  The questions, dialogues and paradigm shifts were alive and well.  I only wish I could have had more time to teach and explore this beautiful part of our country.  I look forward to many more trips to the NW corner of the country.  Olympic PT staff and the new friends I met from the region were awesome! Sorry for all the corny jokes and tangents, but hey I’m Jen Poulin, what would a PRI course be without my stand-up routine mixed in?!” – Jen Poulin

Santa Clara, CA (Pelvis Restoration) – “Thank you Zenith Strength for hosting me this past weekend in Santa Clara, CA.  This course covers a lot of material in two days and with half the class being new participants….whew they got their feet wet. I feel the course participants appreciated our normal human asymmetry with the pelvis having muscles anterior/posterior, lateral, and inferior on both the left and right side that need to be in the correct position for optimal function. Certain muscles on the left or right side need to be “off” or inhibited while others need to be “on” or facilitated.  Joint position influences muscle position.  Once you see it, it’s hard to deny it.  It was a great weekend!” – Lori Thomsen

Tucson, AZ (Myokinematic Restoration) – “I had a fantastic weekend in Southern Arizona discussing the restorative power of the left hamstring. Besides positioning the lower half for tri-planer function, this muscle helps sustain the breathing patterns needed for single leg dynamics without adverse compensation.  Preserving hamstring function allows use of the left adductors without compensation  from the left hip flexors, and also use of the right abductors without compensation from the right lateral ab wall. This type of isolated muscle sequencing is what makes this course so exciting. And, Oh yeah, how could  anyone even  consider a visit to Tucson, Arizona, without dining at my favorite restaurant, Cafe Poca Cosa!”  – James Anderson