After taking the course, I still am a bit confused when it comes to putting together a home exercise program. I understand that there is a treatment hierarchy and I have been choosing exercises from the examples, but there are many other exercises. I feel like I don’t know the rational for choosing some of them.  Do you have any suggestions on how I can learn which of the exercises to choose?

Choosing the best exercises for the home exercise program is frequently a challenge.  You have to remember to stay focused on key AF IR principles and remember that not all exercise are of equal value.  It is easy to be tempted and think that having proficiency with more exercises makes you a better clinician, but the fact of the matter is that being good with a technique and staying focused on the right things is better than being mediocre with a lot of activities that you use at the wrong time in the wrong way.

I understand that when we want to reposition, we use the hamstrings. Why does it tell us on pages 46 & 47 of the Myokinematic Restoration manual that we use the bicep femoris (ER/EXT)? Don’t we want to use the medial hamstrings more since they are so weak? Or do we use the biceps because they ARE stronger?

You asked about biceps femoris and medial hamstrings.  The fact is that we want both.  The biceps femoris is positioned best to sagitally extend the hip (AF EXT) via the sacrotuberous ligament and the alignment of the biceps’ proximal tendon.  But when it comes to the much desired IR during hip extension, then you gotta love the medial hamstrings.  When you break it down a plane at a time, you have to focus on the best sagittal plane muscle first, but when you begin to integrate planes you have sagittal biceps together with sagittal and transverse medial hamstrings (these medial hamstrings are a functional mix between the biceps femoris and the ischial condylar adductor magnus).

A concept that I have learned is that if you evaluate a patient’s ability to step down from a stool with their right leg and you see the left leg’s knee cross midline and femur internally rotate, you assume that their left external rotators are weak and you want to strengthen their external rotators… How does this tie in with AF ER on the left or is it a different way of thinking when it comes to PRI principles?

On the step down test observing left adduction and IR, you have to keep in mind that adduction and IR in left AF IR (pelvis turned left putting the femoral head into the socket) is different than adduction and IR in left AF ER (pelvis turned right putting the femoral head out of the socket).  If they are not shifted into the repositioned state of left AF IR, then what you see is not what you get.  It becomes very compensatory and what looks like weakness is actually the result of poor positioning for all the left side bones, joints and especially muscles (more AF positional weakness than FA weakness).  Be careful making a judgement on simple observation, when a detailed AF and FA performance analysis like the Hruska Adduction Lift Test has not been used to tell you what is actually going on biomechanically.

I have a very pronated left foot. Through other courses I learned that pronation causes my tibia and femur to internally rotate. As a result, should strengthen my external rotators? How does this tie in with AF ER on the left?

A pronated resting left calcaneus (compared to the right) is very common in the presence of the Left AIC.  The frontal plane shift toward the right across the pelvis tends to invert the right foot and evert the left foot as the center of gravity is directed laterally over the lateral border of the right calcaneus and foot.  So it turns out, your very pronated left foot needs a global pelvis repositioning into left AF IR and left adduction to minimize the excessively everted nature of the left calcaneus (and then stability or motion control shoes to hold it there).  Coming out of this eversion (pronated) state then involves training tibial ER and femoral IR.  This is the opposite of the original problem of left hip ER, tibial IR and subtalar pronation.  So in answer to your question, do I strengthen my left hip ERs?  The answer is no.  You’ve got to be careful strengthening hip rotators (FA) until you have strengthened the AF acetabular “hole control” muscles to hold things in the correct position.  If you don’t properly train the muscles that hold you into left AF IR, then you will turn the pelvis back into the Left AIC pattern.  This will give you more left foot/ankle pronation because the center of gravity shifts laterally to the right away from the left subtalar joint.

At the last Postural Respiration course I took the speaker and I both tested HG IR on a friend of mine.  I was getting these huge positive values, but the speaker’s values were negative.  He suggested I was stabilizing the humerus too firmly.  I have seen a “firm” technique on the HG IR test (in fact, when one person tested me, the firmness was quite painful).  I have been reading over the manual and looking on the web page but can’t really find the answer I am looking for.  How firmly do you stabilize the humerus?

A couple of thoughts on the HG IR: don’t over-stabilize the humeral head from being able to both roll and glide during the testing. But do make sure the shoulder joint does not advance forward during the rotation. Its one thing to stabilize a joint and prevent it from moving forward and yet another to press so hard on the joint structures that it is not allowed to passively move as it should up to the point of impingement.

I have two new patients that have a “spasmodic” exhalation and a cough with exhalation.  I think this was mentioned during a course but wanted to clarify the reasoning for it.

I really believe there are two components of coughing or “spasmodic” activity with deep exhalation or during or following PRI manual techniques to the chest wall. One is the oral or pharyngeal reflexes that could be stimulated and the other is the actual ‘pull’ on the hyoid, pharynx, cricothyroid and esophageal area because of overall tissue shortening/tightness of the anterior neck region, secondary to forward head posture, enlarged tongue base, accessory respiratory muscle overuse, airway narrowing (obstruction) or torsion of cervical tissue or all of the above. I see this a lot and after maintaining cervical neutrality the cough – or exhalation issues diminish.

-Ron Hruska

For the Hruska Adduction Lift Test, one thing I want to ask about is the patient to therapist size ratio.  I’m a tall guy, when I perform this test I really try to keep the upper leg at a “reasonable” height for the patient’s body.  It also seems that the passive hip abduction test will highly correlate.  Can you comment on this?

I have frequently been asked this question in classes across the country.  In short, the height of the examiner is not a significant issue up to a point.  There appears to be range of tolerance with regard to ability to perform the test and the height of the examiner.  Normal abduction is in the order of 45 degrees.  If the examiners’ height takes the LE well-beyond 45 degrees then height might become an issue.  I am 6’1” and have yet to discover anyone that I felt was adversely affected by my height. However if I were Shaquille Oneal and my patient was less than 5 feet then height could become an issue.

At that point I still have some options: 
1. call in another examiner
2. place the top most lower extremity on the wall (which I hate to do since I
like to feel what the top LE is doing)
3. use the Abduction Lift Test since there is a good correlation between the
two
4. all of the above!

The test is helping us understand how well the patient can recruit and inhibit multiple muscles so we want to be sure that we score accurately.  In fact, another name for the test could be the: “How Well Do You Shift Into Acetabular Femoral Internal Rotation And Recruit And Inhibit Muscle Test” but it’s kind of long and that acronym HWDYSIAFIRARAIT just doesn’t flow.

– Mike Cantrell

I was wondering if there is any correlation or known cases regarding right LE dystonia and the Left AIC pattern.  I just evaluated an 18 year-old female with a 3 year history of right LE dystonia (right foot is plantarflexed and inverted).  She also presents with a very clean L AIC and bilateral BC pattern.  Her right LE is 2 1/4 inches shorter than the left.  She has been treated unsuccessfully for 2 years with traditional physical therapy (US, stretching, massage) and botox injections.  I have started her on a repositioning program in supine and sidelying, but was wondering if there was anything I could try to inhibit the posterior tibialis tone and engage the right peroneal group.

I don’t know of any specific case studies or research or publications that are related to right LE dystonia and the Left AIC pattern…although I’ve seen a number of patients who have a Left AIC pattern with cervical dystonia, focal dystonia of an extremity, thoracic dystonia, etc.  I get the official dystonia publication monthly and am always looking for articles related to your question.

I would reduce as much right adduction activity out of her life as possible and integrate left AF IR , left adductor upright stance activity with right abduction or introduce simple techniques as the left sidelying IO/TA and left adductor with right glute max.  Where she really has to work hard at maintaining right FA ER without losing right calcaneal eversion, so that she can adduct her left LE with FA IR.  She would probably benefit from more awareness of her left LE during left AF IR stance and needs to be more aware of left sided balance, load, etc.

In Myokinematic Restoration, James Anderson talks about how tightly woven anatomically the psoas major is into the right diaphragm leaflet. Can we then assume that activation of the right psoas can be used and is advantageous to use as a method of activating the right diaphragm/pulling it down to enhance right intercostal expansion?

The interesting thing about the psoas major and the diaphragm is that they have similar influence on the spine in the sagittal plane, but they have an opposite influence on the spine in the transverse plane.  In other words, in the transverse plane, the right psoas major compliments (or is agonistic to) the left leaflet of the diaphragm; and the left psoas is agononistic to the right leaflet of the diaphragm.  They work with one another through their “tightly woven” attachments ipsilaterally in the sagittal plane to enhance the extension activity of an extended patient, but work with each other contralaterally across the anterior vertebral bodies in the transverse plane.  So, if you activate the right psoas, you are enhancing the sagittal influence of the right diaphragm leaflet and the transverse influence of the left leaflet (something that is desirable in both planes at both of these sites).
As far as using the right diaphragm to enhance right apical expansion is concerned, its incorrect to view it that way.  In fact, it is the torsional respiratory influence of the left diaphragm (not the right) that is primarily responsible for expansion of air into the right chest wall and mediastinum.

During the Myokinematic Restoration course the instructor says “teach patients to abduct without using the right abdominal side wall not the right vastus lateralis.”  How would someone use the VL to abduct if it doesn’t cross the hip?  How would you teach someone not to use his/her VL in any case?

With the typical Left AIC patterned individual the right VL is engaged, short and strong acting as an abductor and internal rotator.  So positionally it is short and from a compensatory standpoint it has an increased demand as an abductor as it struggles with TFL to abduct the femur via the extensor mechanism (the very structure supporting it for IR).  You are not teaching someone NOT to use the VL, you are actually attempting to reduce demand on the VL by allowing the patient to shift out of right AF IR and into left AF IR.  This must happen during gait and does not with the typical Left AIC patient.  Until the patient can shift into left AF IR he will have increased demand on the right VL even when weight bearing on the left LE.

The typical tri-planar positions for the Left AIC pattern are sagittal, frontal and transverse?  What do I need to do to restore the patient (Left AIC) to neutral positioning?

Start in the sagittal plane activating left biceps femoris for posterior pelvic rotation, then go to frontal plane via left IC adductor and finally right glute max for transverse plane motion of the pelvis into left AF IR.

What are the weak muscles when in a Left AIC pattern?

Please reference page 18, 19 and 20 in the Myokinematic Restoration course manual under the title “Positional and Compensatory Influences of the Left AIC Pattern on Muscle of the Lumbo-Pelvic Region” and you will see a concise answer to this question.