I am working with two people that have had right hip replacements.  I’ve done the testing and given them the basic repositioning exercises.  Are there any specific PRI recommendations for hip replacements? 

The most common specific recommendations by MD’s are to avoid adduction past midline and internal rotation past neutral for 6-8 weeks. If your patients are many months post-operative you could go after adduction and internal rotation and AF IR development bilaterally. This would increase their gluteus maximus strength and control of their FA movement. There are many PRI techniques that would be appropriate; we are partial to seated, prone, and standing reciprocal pull backs with adductors, medial hamstrings and anterior gluteus medius muscles on.

What type of ankle brace would you recommend for someone with chronic ankle sprains?

Swede-O Inner Lok 8

Can PRI help posterior compartment syndrome?

Because PRI uses principles to reduce gastroc-soleus demands and increase glutes and hamstring activity there is reason to believe that the tightness and restriction at the posterior compartment would improve with better transverse, sagittal and frontal plane activity at the acetabular-femoral musculature and not through the tibia and fibula musculature.  PRI’s approach can influence or effect unilateral plantar flexors, tibial calcaneal stabilizers and leg fascial compartments. 

I’m trying to find information on “Avulta Procedure” used for pelvic floor prolapse.  I am trying to figure out how the surgical technique is done in order to understand how the mesh is fixed and which tissues may be potential problems as a result of the fixation and subsequent restrictions.

Here is what we know about the procedure: 
Avulta is a product used for pelvic floor reconstruction.  It is a type of synthetic mesh used in a sling operation or tension free vaginal taping.  The type of procedure to install the mesh varies from MD to MD.  Most of the doctors we work with use the tension free taping, there are no surgical suturers or attachments but there is of course a lot of soft tissue disruption.  The “natural” type of mesh adheres to normal tissue and scars down to give support.  The type of procedure depends on the type of dysfunction and severity (SUI, organ prolapse).  
There was a fairly good picture of the portal holes on Bard Urological (seller of the product).
Part of the problem with the procedures is that the biomechanics of why they have prolapsed may have never been corrected, scar tissue built on an unstable, asymmetrical pelvis can certainly lead to pain and reoccurance of symptoms.  Most often these patients need manual releases after the pelvic position is corrected.

“I have question concerning page 63 of the postural respiration manual. Written on the third row down is the term…All tests are – and sufficent right scapular-thoracic function and position exists.  What is meant by this phrase and how do I know when the patient has obtained this”?

The tests we are referring to are left horizontal abduction, left cervical axial rotation, left humeral glenoid flexion, right and left apical expansion, and right HG IR.  If these tests are all negative and the patient has the ability to reach forward in supine, with arms extended, without losing position of the thorax (all previous tests would indicate that) then I would recommend standing right low trap and right tricep PRI activity.  Standing places gravitational forces on the scapula and if good anti-gravitational support is offered by the right serratus anterior, middle and lower trapezius and atmospheric pressure then upright re-training and correct neuro-motor timing of upper extremity flexion should be able to occur without losing thoracic flexion.  If it cannot then right low trap and right tricep co-activation using PRI non-manual techniques should take place in any of the previous non-standing or non-upright positions.

We have also added this criteria on page 63 of the course manual.  To get a replacement copy, click here!

I am currently treating two different patients who work in a hospital setting.  One is a patient transporter, pushing wheelchairs around and one pushes around carts full of surgical equipment. Neither of these patients can swing their arms during their work day. What kind of problems does lack of arm swing cause and what would be your recommendations?

We actually had a long discussion about arm swing and the importance of gait and reciprocal activity last week.  Lack of arm swing indicates the patient’s inability to shift into AF IR and also the position that the spine is oriented in.  If someone demonstrates no arm swing on the right, you know that their spine is oriented to the right.  With a patient like this, we would go after Left AF IR…a lot!  Once you can get them to shift into their left hip, you know that they will regain motion in their arm.  After we have established left AF IR, we would teach them alternating reciprocal gait.  With this type of patient, your best treatment will center around their gait activity.  This handout will help a lot!

Why are so many of the PRI exercises isometric, rather than using the more typical type of PT exercise that uses movement against resistance?

PRI non-manual techniques are organized by muscle, position and suggested sequence of progressive application.  Therefore, each technique precedes a technique that requires increased neuromotor integration, increased inhibitory activity from compensatory patterned muscle, and an increase in multilevel tri-planar positional organization.  In order to carry this type of function out, the patient needs to “find” and “feel” isometrically a specific muscle in a specific position to learn a behavioral pattern or strategy with this isolated muscle engaging into an integrated “family” of muscle, without dropping off because of position or sequence of movement events.  Many of the more integrated techniques do incorporate “movement against resistance” while the early techniques in each position on initiation, are isolated to inhibit undesirable compensatory activity and identified by the patient for later integration neuromuscular non-compensatory function.  Without awareness of this identified and isometric trained muscle, higher levels of neuromotor demands could reduce the needed concomitant activity of this muscle. 

I am seeing a patient that has lymphedema in the left side of her face and neck.  She had a tonsillectomy in June 2007. They discovered she had Eagle Syndrome and was referred to Mayo Clinic where they removed 2cm of her styloid bone.  She has been having increased drainage from parotid gland and increased saliva since that time.  She does have a lot of the TMCC facial features.  We have been doing manual techniques with her, along with lymphedema treatments.  She looks much better but continues to have drainage and nausea. 
Have you come across anything like this? Do you have any suggestions or insight?

The drainage and nausea could be related to cranial imbalance; which we have seen and have treated with limited success (usually there is a cervical imbalance, occipital imbalance, temporal rotation, etc…associated with styloid surgery).  This all places torque on the sinuses and autonomics.  We would suggest that you continue to develop strength at her left abs and both lower traps and work on thoracic flexion with respiration.  She may need an appliance to take her out of her bite.

I am looking for help to close my rectus diastasis. Any suggestions? I have done several things but have only had minimal improvement.

From our experience with rectus diastasis, there is no way to actually close the diastasis without surgery.  However, we do not recommend that you get it surgically repaired, this will only further complicate things.  You can, however, help bring the muscles together to allow for proper healing. 

With a rectus diastasis, you will have a decreased infra sternal angle.  Your lower ribs will be in external rotation and you will be in a hyperventilatory state.  This means that every time you go to inhale, your ribs are already flared out (external rotation) so the breath you draw in is only spreading your ribs and abdominals further apart. 

The best treatment for you would be to work on thoracic flexibility so that you are able to properly work your obliques to pull your lower ribs down or to pull your spine into thoracic/lumbar flexion making the diastasis pulled together.

On the current technique of the week it is labeled as a left glute max exercise.  When I do this exercise, I seem to be recruiting the right glute max instead.  Am I missing why the exercise is named “Left Glute Max”?

Yes, you are right, you will probably feel your right glute max more, however, that is not what the exercise is designed for. 

The exercise is intended for you to find your left glute max in a lengthened position (AF IR).  In a Left AIC pattern, the left glute max will be stronger than the right.  But, the left glute max is strong in a shortened position due to the left innominate being forward.  When you have an individual shift into left AF IR, it places the glute max fibers in a long position.  This exercise is intended for you to stay in left AF IR while working your glute max in an FA ER position.  Even though you are not actively turning the left knee out, the resistance of the band causes you to work the FA ER fibers (glute max). 

“Contralateral activity from the gluteus maximus as a femoral acetabular external rotator (FA ER), while maintaining left acetabular femoral internal rotation (L AF IR), makes this an excellent technique to facilitate femoral or acetabular external rotation on the right during recognizable, concomitant proprioception input from the same muscle group in a different position on the left.” –Ron Hruska – Technique of the Week

I am seeing more clients with longer left legs even when the client’s ASIS is anteriorly tilted on the left.  Would this be because the right abs are tighter and stronger on the right side?  Or is the anterior tilt of the pelvic causing the ipsilateral leg to be longer?

Most often when we see a “longer left leg” it is secondary to one of these issues:

Iliofemoral or pubefemoral laxity
Anterior capsule hypermobility or posterior capsule hyopmobility

I would say in most cases we see ligament laxity that increases the leg length.  In these cases, we really go after the patients left anterior glute med.

I treat pelvic floor dysfunction and I have a patient with problems with constipation and pain.  She has very poor hip mobility as she has recovered poorly from knee and hip total joint replacements.  How does squatting effect the pelvic floor and constipation?

I would highly recommend reading Nature’s Platform by Jonathan Isbit.  It will help to answer a lot of your questions about squatting.  The puborectalis muscle attaches from the pubic rami and back to the coccyx.  I don’t know what position your patients pelvis is in, however, in a Left AIC or PEC pattern the pelvis is forward and the coccyx is extended causing strain to the pelvic floor. The puborectalis muscle is shortened causing constriction around the anal sphincter, thus contributing to constipation pain.  The squat allows the pelvis at the coccyx to flex, ribs to go down, and ability to shift into the hips.  This allows the pelvic floor and the puborectalis muscle to relax.  Therefore, gravity and thigh pressure on the colon will aid in defecation versus the patient pushing against a pelvic floor on the toilet (Valsalva) where the puborectalis muscle is tight.

A lot of patients aren’t able to squat, however many of the PRI activities start with small squats.  It’s important for weight to be through the heels and the abdominals on.