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“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!

 

Like most of you, I am a clinician when I enter this site.  But like many of you, I am a spouse, parent and community member as well—just a person.  These blogs are written as pragmatic, candid discussions about my experiences as a PRI practitioner.  Like you, my treatment style is a product of the training I have received.  That training has come from a wide variety of sources—so I certainly qualify as eclectic by definition.  However, every good clinician uses their most powerful and effective tools the most, whether they process that fact or not.  I am no different in that regard either.

From time to time over the years, I’ve fielded questions about whether I am a PRI “fundamentalist.”  This is a good question, and one worthy of discussion.  The well-intended question is “do you use ONLY PRI to treat your patients?”  The short answer is “No.”  The longer, slightly more complete answer is “when I treat a patient and they return to clinic objectively neutral with PRI functional tests that equate to the level of functional strength that they desire but still have focal symptoms, then I treat with focal treatment techniques.”  I use my most powerful and effective treatment techniques first and often times don’t need others.  And yes, the most powerful techniques I’ve ever utilized are PRI techniques.

That said, I think it best to discuss this concept by way of actual clinical examples.  The following is a story about one patient with the diagnosis of left shoulder biceps tendinosis who I treated intermittently over an 18 month span, the strategy I used to treat him and the clinical results that I found.  Names have been changed to protect the innocent and in order to maintain a readable text, I have grossly summarized the care of this patient.  The clinical findings listed are predominantly to give the reader a feel for the symptomology, goals of the patient and style/type of treatment used.

Don’s Story:

Diagnosis:  “biceps tendinosis”
“Caused” by AC jt spurring, subacromial impingement according to his physician, the radiograph and MRI

The mechanism of injury was insidious, first becoming a limiting factor 3-4 months prior to evaluation.  The patient’s ROM was functionally limited into abduction, flexion and IR, less limited with ER.  There was noted adverse neural tension with median and ulnar nerve biased UENTT’s.  Neer sign, Hawkins Kennedy and empty can tests were positive.  Comparable sign with resisted elbow flexion and supination, active and resisted horizontal abduction.    PRI testing revealed a PEC patient who showed a bilateral BC pattern. 

The patient wanted to be able to raise his arms overhead to enable him to perform various ADL’s including woodworking, wanted to be able to again play his accordion, which he had been unable to do for several months.

This was a classic example of working with an “old-school” orthopedic physician and patient.  Good physician, hard-working patient.  I initially described the positional influence of the brachial chain because I knew it was most important and tried to treat the patient in that fashion.  However, the patient’s script for PT from the physician was specific and called for scapular stabilization, rotator cuff strengthening and the patient had discussed specifics about what PT would involve before arriving.  When what I felt was best for the patient was not supported by the patient or his physician, I chose to follow the script as directed.  I did what was comfortable and familiar to the physician, patient and myself—I used an ‘eclectic’ approach which included:  As much “PRI” as the patient would tolerate–a few non-manual techniques to attempt to reposition, Butler neuromobilizations to address adverse neural tension, Gr I-III joint mobilizations to inhibit tone and mildly increase posterior-inferior capsular length, MWM’s to achieve end range pain-free ROM (IR and abduction most notably in this case), pain free rotator cuff, ST AND TS stabilization to the hilt.

After using this approach twice per week for 8 weeks, the patient had achieved all mobility goals, and all but one functional goal.  He still could not play his accordion for more than 5 minutes without having symptoms of left shoulder pain but was happy with his progress, reporting he was 90% better.  At his 8 week f/u with his physician, the decision was that he was “better enough” and was to discharge to HEP in short order.  I outlined his final HEP that he would agree to and wrote a semi successful discharge summary to “continue with independent HEP per physician’s orders.”

Sounds like a common 90% successful PT intervention, right? I had met all of the mobility and all but one of the functional goals that I had set and the patient and physician were pleased with my work.  I had done exactly what they had asked.  So why wasn’t I entirely happy?

To be continued…

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

It looks like we are going to have beautiful weather for our 6th Annual Interdisciplinary Integration Symposium this week. Safe travels to Lincoln!

This was the second time that I had the pleasure of teaching at Finish Line Physical Therapy in New York City, and I am always grateful for their genuine appreciation and interest in PRI. After a weekend of Postural Respiration, I know most of them will not forget how to integrate left abdominals with left posterior mediastinum and right lateral thoracic expansion. I hope they became "lifted" as much as they "lifted" me on a wonderful rainy weekend in New York!