Recent Blog Entries
Posted 05/16/2013
After completing my last of three internships at clinics with PRI therapists, I am more aware than ever that I have only experienced the tip of the iceberg as far as what the science of PRI has to offer patients and the healthcare profession as a whole. For my current clinical instructor Jason, exploring the depths of the iceberg has included a greater understanding of the function of teeth in helping to provide the rest of the body with postural stability. For Dr. Heidi Wise, it has included discovering how the visual system impacts the body’s movement patterns. In fact, every PRI therapist is on a wondrous journey of discovery as their clinical expertise continues to expand every day with every patient. The expert PRI practitioners at the Hruska Clinic are constantly advancing the science of PRI, and I am thankful for every one of them for all of the “ah-ha moments” I have had during my last internship. I am also thankful for every one of the patients who shared their stories with me to help me be a better clinician after I graduate.
Following are some “ah-ha moments” from my last week of this extraordinary experience:
• The PRI course manuals and techniques cannot cover every possible unique situation. I saw Ron treat patients with innovative exercises that will never be seen in a course manual because the particular issues that necessitated the exercises are rare. Some factors that might cause a treatment plan to deviate from or go beyond typical algorithms are multiple surgeries or other trauma, a fixed deformity, activities requiring a high level of performance, and imposed dental or vision changes.
• I had an important duty to carry Ron’s milk bucket from the farm around the UNL campus as Ron was meeting with various people. He taught an important lesson during an inservice about resiliency, which is loosely defined as the ability of something to bend or deform and return to its original state. Ron demonstrated with a plastic dog biscuit container that was easily crushed, and there was no returning it to its original state. On the other hand, a ceramic mug is so strong that you could put a board on it and stand on the board without breaking the mug (don’t try this at home!). Ron did not stand on the mug, but with a light tap on a table, the mug broke into several pieces. Like some of our patients, the mug has too much strength because it is easy to break. The plastic milk bucket has an ideal combination of strength and “toughness”; it is resilient because you could run over it with a car, and it would still pop back into shape. We want our patients to be resilient – to be able to flex after extending, to be able to internally rotate after externally rotating, to be able to bounce back from injuries and other life stressors.
• I encourage the therapists in the reading audience to take the time to broaden your working knowledge of non-manual PRI techniques. Don’t limit yourself to exercises you learned at a course. You will be better able to customize interventions to the specific needs of individual patients and will likely make more progress in a shorter period of time.
• A 13-year-old patient who has been experiencing migraine headaches, neck pain and back pain since she began wearing Invisalign had bilaterally limited HG IR, HG horizontal abduction, cervical rotation and sidebending, and apical expansion. She became neutral after walking with a flat plane splint placed on top of the Invisalign on her bottom teeth. The Invisalign was locking her teeth into place, which locked her jaw, neck, and mid-back and inhibited her breathing. The plan of care for this patient included exercises for better positioning of her thorax, head and neck, genioglossus exercises to facilitate the tongue’s function as a reference center, and wearing a splint at night so that the teeth can still move while the Invisalign is still in place.
• Here is a great Jasonism: “If breathing is not normalized, no other movement can be.”
• If a patient is not progressing in therapy, be sure to re-test him or her bilaterally. Something might have been missed if only the side that tends to be positive was re-tested. In addition, manual muscle testing in combination with asking the patient where he or she feels it may reveal unexpected weakness.
• Blowout party favors may be used to facilitate exhalation as an alternative to using a straw or a balloon.
• The patient whom I mentioned in my last blog with shoulder tendinitis and a minor rotator cuff tear cancelled her third appointment because she was feeling so good after being given exercises to improve her right apical expansion, right trunk rotation and abdominal integration during the first two visits. Torin hopes that she will return because there is more that can be done to help maintain good positioning for healing, such as working on engaging the right triceps and right low trap. It is important to educate patients that goals for PRI therapy go beyond reducing pain to improving function and performance and preventing future injury so that patients know there are benefits of continuing therapy even after they are feeling better.
• It is also important for patients to understand which muscles they should feel during their exercises. An exercise should be discontinued if the targeted muscles cannot be felt.
• As Jason and I were looking at spatial relationships among some bones, I created this picture with the Apple app 3DSkeletons:
Can you identify these bones? A quick glance might fool you into thinking the primary structure visible is the pelvis, but take a second look. This is a top down view of the temporalis and sphenoid bones with the pelvis visible at the bottom through these cranial bones. This view showcases the similarities between the temporal and innominate paired bones of the body, which is remarkable especially when one considers how the movements of both are similar during respiration.
As a final note, I would like to give some special thanks:
• To those of you who have been following my blogs…Thank you for your interest!
• To Jason…Thank you for your encouragement and confidence in my readiness to treat patients!
• To Ron…Thank you for passing on your knowledge and insights that are inspiring purpose and passion among healthcare and performance professionals to enhance the RESILIENCY of their patients and clients!
Posted 05/13/2013
This may sound like a silly question, since we all started walking when we were toddlers, but I find that many of my patients do not know how to walk. I see this everyday when I watch my patients walk up and down the hallway. Gait is a term for walking, and there are many phases in the gait cycle. The first phase of walking is heel strike, and many people have poor heel strike on one or both sides when they walk. If you avoid striking your heels while walking, you will alter the proper mechanics at your foot, ankle, hip, back, etc. Since heel strike is the first stage of the gait cycle, you have now altered the entire sequence of walking. Your body has to compensate for this, and will likely lead to pain or dysfunction.
I would recommend paying more attention to how you walk. When you take a step, do you hit your heels first? Your heel should hit the ground, and then you should feel the arch of your shoe, followed by pushing off your big toe. A simple exercise I would recommend to help you recognize heel strike is to first walk backwards, feeling your heels hit the ground first. This helps to stretch (or inhibit) your calf muscles. Walk up and down your hallway a couple times each morning backwards. Follow this up with walking forwards slowly and placing an emphasis on hitting your heels to the ground first.
If you don’t know how to walk, you will have difficulty running or doing other activities pain free. So, let’s go back to being a toddler and learn how to walk again!
To email Jen with questions or comments, !
Posted 05/07/2013
of how Jason helped her when years of physical therapy, surgery and medications didn’t. Click here for Debbie’s success story!
Posted 05/02/2013
The therapists at the Hruska Clinic are constantly developing new ways to teach and demonstrate how the body functions, so it has been an adventure to be involved in some of their thought processes as I try to assist in looking for relevant resources. One thing that I have found is that it is not easy to find any that recognize common movement asymmetries. The latest wild goose chase that Jason sent me on was to look for a depiction of how rib position can affect scapular position and motion. Well, this is the best goose that I could find. He must have good right apical expansion because he can lift his right wing and stand on his left leg!
In addition to chasing a wild goose, I did have some “ah-ha moments” this past week during my internship that I would like to share:
• The goose pose above reminds me of the Single Leg Right Apical Overhead Reach exercise that Ron gave to a patient still in her first decade of life who had an overactive right SCM and needed more right anterior and lateral chest wall expansion because hers was more of an ascending issue.
I thought this picture of the exercise would be helpful to include, although I realize that in showing the similarities between Jason and a goose, I risk failing this internship and having to redo it (if only I could have such luck!). Ron did not want to burden the young patient and her family with too many exercises, so he only showed her one more, a Left Foot Centering Technique on a 2” wide block that will help to correct the patient’s tendency to center on her right side. For functional and fun activities, we also showed her a Sidelying “Rest” Position for watching TV and had her blow up a balloon without being concerned about details of the technique, such as putting the tongue on the roof of the mouth and avoiding pinching off the balloon with the fingers. In fact, Ron had her blow up her balloon bigger than his, and then he used the two balloons to draw a diagram of how the right side of her chest was like his balloon and needed to be bigger. Seeing her bilateral HG IR tests go from positive to negative after blowing up a balloon dispelled any concerns that I had regarding imperfect technique in blowing up the balloon. Climbing and other activities involving reaching with the right arm while pushing with the left leg were also encouraged. It was a privilege to work with this patient and her family, and I foresee in the future that some PRI therapists might have an interest in focusing on the pediatric population.
• Is it all right to continue with an exercise if a patient has difficulty breathing while doing it? This is actually often to be expected with some PRI exercises, and it is helpful to warn the patient beforehand that he or she might have a hard time breathing at first, but it should get easier. Examples of exercises that might cause difficulty in breathing include the Squatting Bar Reach, Standing Supported Passive Left AF IR with Right Trunk Rotation, and Right Sidelying Right Apical Expansion with Left FA IR. It is also instructional to show patients how much easier it is to breathe when certain exercises are done on the other side.
• A couple of patient education resources that might be forgotten because they are not included in the non-manual techniques CDs are the PRI Positioning Handout and the PRI Right AIC Reciprocal Alternating Gait Recommendations. The tips on these handouts will help patients to maintain neutrality throughout the day with reference centers.
• When manually facilitating rib internal rotation, avoid pushing the ribs straight downward toward the table. Instead, follow the direction of rib movement toward the opposite hip. I definitely felt more discomfort when Jason performed the technique incorrectly on me as a demonstration. In addition, as a smaller person, I have had to be sure to use good body mechanics when performing a two-person infraclavicular pump to match Jason’s pressure on the other side. For a patient with stiff ribs, it was all I could do to maintain opposition on the left side to help the patient to get air into the right chest wall while Ron performed a manual right pec stretch, even when the patient was pre-positioned with left thoracic abduction.
• Another patient who needed increased right chest wall expansion was a student and saxophone player with right shoulder pain and limited right HG flexion due to a tight right latissimus. Along with other exercises, he was given a couple of stretches that I have found personally to be very effective, the Standing Latissimus Stretch and the All Four Intercostal and Latissimus Inhibition. For the latter exercise, I felt a more intense stretch that included the QL when I extended my right leg instead of the left as the picture shows in the instructions. In addition, I noticed that the Standing Latissimus Stretch looks very similar to the Standing Quadratus Lumborum and Intercostal Stretch, which does not inhibit the latissimus as well because of the more internally rotated shoulder position.
• Torin saw a patient who is an example of why I first became interested in the science of PRI. The patient had a common condition that is easily explained by anyone who understands the consequences of limited apical chest wall expansion, but it is a condition that is often difficult to resolve with conventional physical therapy. She had a gradual onset of right shoulder pain that became acutely exacerbated a couple of months ago while she was painting her house with her right arm overhead, and she was diagnosed by a physician as having a right shoulder tendinitis with a minor rotator cuff tear seen on an MRI. Her initial home exercise program included the 90-90 Hip Lift with Right Arm Reach and Balloon, the Seated Right Chest Expansion, and the Standing Quadratus Lumborum and Intercostal Stretch. Despite having some difficulty with the balloon, after one week her shoulder pain decreased, her right HG active flexion increased from 100 to 170 degrees, and right HG IR increased from 10 to 80 degrees. During her second visit last week, the patient practiced the 90-90 Hip Lift with Right Arm Reach without a balloon and a hip shift was added to the exercise. Her right HG IR then went all the way down to 90 degrees. The rest of the treatment was focused on right trunk rotation and abdominal integration. Torin mentioned that manual techniques would have been performed if she had not been able to achieve neutrality with the nonmanual techniques. Experienced PRI therapists may be yawning out there because this is a fairly routine patient case, but the patient expressed her amazement, and I still marvel at the overall simplicity of the plan of care and the rapid improvement experienced by the patient.
• Sometimes it is appropriate for patients to perform exercises bilaterally. For instance, a young soccer player with overactive TFLs bilaterally was given both the 90-90 Supported Hip Lift with Hemibridge and the Supine Hooklying Supported Left Glute Max with Left Adductor to perform bilaterally to activate the glutes, hamstrings, and adductors and inhibit the TFLs on both sides. His Straight Leg Raise test improved from about 50 to 60 degrees bilaterally to 90 degrees bilaterally after he did the exercises. Whoa, pause for a moment to think about what just happened – exercises to improve hamstring activation increased Straight Leg Raise range of motion! Again, I hear the yawns coming from PRI therapists, but the rest of the world is trying to stretch hamstrings to get the legs higher without an appreciation for the influence of pelvic position on hamstring length. I am probably going to answer this question wrong on my upcoming national board exam…
• I had the opportunity to preview the new Pelvis Restoration Home Study course and was struck by a comment that Lori made about one of Ron’s overweight patients in a PEC pattern who lost 30 pounds after doing nothing different other than learning how to blow up a balloon. After he learned how to breathe and his muscles were put into an optimal position to burn fat and to integrate triplanar movement during exercise, he lost a total of 100 pounds.
• The previous example as well as situations where parents bring in their children during their developmental years for therapy and other cases when patients have a goal to avoid, as one patient put it, “heading for disaster”, all indicate that the PRI approach has the potential to play an important role in prevention and wellness activities, a growing trend in physical therapy.
Be sure to catch next week’s last chapter in my blog series!
Posted 04/24/2013
Have you ever wondered how all the PRI exercises were developed? The exercise shown in the picture probably won’t make it into your top 10, maybe not even your top 100, but Jason had fun rigging me up as he and Ron laughed about the first time they came up with this. A long piece of tubing is tied to my right ankle, wrapped around the handle of a single point cane, and tied to the gait belt around my waist. I am pushing the cane toward the right to create an abduction moment at my right hip. During the right swing and left stance phase of gait, I could feel my left adductor and left glute med engage as I went into left AF IR. You can see in the picture that my weight is centered over my left foot. This exercise never made it into the new PRI nonmanual techniques CDs, but it’s ingenious!
As usual, the sixth week of my internship at the Hruska Clinic was full of “ah-ha moments”:
• Something that really strikes me about the PRI approach, especially after seeing how well patients have been progressing through the weeks, is that patients are able to experience improved outcomes without having to do a lot of exercises and without having to come to the clinic multiple times a week. As a typical example, a high school sophomore active in sports began having issues with left ischial tendinitis last spring, and it progressed to the point where he had constant pain with sitting and has had to sit out during track this season. He was evaluated during the second week of my internship and was given 3 exercises during that session and 3 other exercises a couple of weeks later. By the second visit he was neutral and not having any pain with sitting. During his third visit the patient had Hruska Adduction Lift Scores of 3/5 bilaterally and reported that he had played basketball for 2 hours. During that session he was given 3 standing exercises to continue his home exercise program. Going forward, the time in between PT visits will be increased to approximately 3 weeks, one month, and 6 weeks so that the patient will probably only need to be seen 3 to 4 more times before fall football starts. His next session will be focused on alternating, reciprocal activity with a goal to progressing to mimicking sports activities with his exercises.
• In PT school I learned the importance of using clinical outcome measures that are functional. The Hruska Clinic uses the Patient-Specific Functional Scale, which was designed to measure functional change in patients presenting with musculoskeletal disorders. Its validity and reliability have been studied in a variety of conditions. I like it because it is a quick and easy questionnaire for patients to complete, and it focuses on the activities that are most important to patients. Remember that taking into consideration patient values and preferences is an important component of evidence-based practice.
• Speaking of evidence-based practice, research on physical therapy interventions is replete with inconsistent and inconclusive findings that have left many of us frustrated when we make a sincere effort to use the literature to support clinical decisions. I believe that a major threat to internal validity in many studies is there is an unappreciated uncontrolled variable among the study subjects, which is each individual’s underlying pattern of neuromuscular imbalance. When a study has strong internal validity, that means there is good evidence that the treatment alone caused what was observed (the outcome) to happen and that it is unlikely that an alternative cause (a confounding factor) influenced the results. For randomized controlled trials of physical therapy interventions, internal validity would be strengthened if all participants, including the ones in the control group, were in a neutral position. Perhaps an underlying left AIC or PEC pattern might have lessened the potential efficacy of a particular treatment because the patients were not in an optimal position to receive the intervention. Neutrality is a starting point, not treatment, and it should be a starting point for many types of therapy, not just those based on PRI techniques.
• I saw an example of integrative therapy in action when Jason and I went to a patient’s dental appointment to ensure that the patient was in a neutral position before her splint was modified. Although Jason had not worked with this particular dentist before, the two had discussed their shared goals on the phone prior to the appointment. Each healthcare professional had a good appreciation for the other’s expertise, and they were able to find common ground on which to work closely together to ensure that the patient would have the best opportunity to find a position of rest with improved occlusion.
• I had a really big “ah-ha moment” when Jason called an Adduction Drop Test result negative for a patient with wide hips whose knee did not go all the way down to the table. I learned the quality of the movement is more important than whether the knee touches the table, especially for a patient with wide hips. After all, the intent of the test is to assess whether the hip position will allow adduction.
• For a patient who experienced “gripping” chest pain four times in the last couple of months with a negative work up at the hospital for a heart condition, part of her breathing retraining included a strategy to manage another episode if it occurs. The patient was instructed to sit with her elbows on her knees and breathe with long exhalation. To encourage the exhalation, Jason suggested that she read out loud or sing as long as possible before inhaling. He mentioned that this is also a cognitive strategy in that as she listens to herself, it will take her mind off the pain.
• Differential diagnosis is becoming an increasingly important aspect of physical therapy practice as most states permit direct access to physical therapy services. One issue that has come up frequently is muscle pain resulting from statin therapy, a common pharmacological treatment for high cholesterol. Also, we have at least one patient who might be experiencing joint pain and swelling from a previous course of fluoroquinolone, a common antibiotic that may be prescribed in the form of ciprofloxacin, levofloxacin, and moxifloxacin. These are some drugs to inquire about for patients who present with muscle and/or joint aches.
• Also related to the topic of differential diagnosis is a case of a patient with a rash and neck pain that followed a dermatomal distribution pattern. She was diagnosed by a dermatologist as having shingles, so it is possible that her pain might persist if she develops postherpetic neuralgia.
• For patients with low back pain with radiculopathy, it is often informative to find out if placing the patient in left AF IR or activating the muscles that facilitate this position changes the pain. One patient felt relief in a left stance position with a left arm reach for right trunk rotation. Another patient felt the tingling disappear when she activated her left adductor and right glute max in various sidelying positions. This is another example of how the A-B-A design that I described in a previous blog may be used to educate the patient as well as build on clinical expertise.
• For patients with acute lower extremity radicular pain, Passive Dorsal Thoracic Inhibition may be helpful to reduce the compressive forces in the spine. Instead of placing the feet high with knees extended as shown, patients may place their calves on an ottoman or something similar. Patients can replicate this at home with the Dorsal Thoracic Inhibition exercise. A modification to this exercise that might be helpful is to place a small towel roll under the pelvis to provide some passive support for the pelvic tilt.
• Jason has a treasure trove of articles related to PRI, and it’s hard to keep up with the new ones he keeps finding! Here are some interesting thoughts from an article by Malcolm Levinkind, “Consideration of whole body posture in relation to dental development and treatment of malocclusion in children” :
...Once the baby starts to walk, usually at around twelve months, this is when the first deciduous molars erupt...One can speculate that the eruption of the first deciduous molars may provide some posterior dental support and this vertical dimension can also contribute to the stability of the head and neck....It is interesting to note that animals that are born and have to stand immediately to become mobile are usually born with teeth. For example, this occurs in horses, elephants and buffalo. Whereas animals that do not have this requirement, such as marsupials, do not get teeth until much later.”
• With so many exercises to choose from, it is important to understand subtle differences between similar exercises. For instance, the Standing Supported Left AF IR with Resisted Right FA Abduction is more difficult because there is a longer lever than with the Standing Wall Supported Left Knee Flexion with Resisted Right Glute Max. For the second exercise, additional support may be provided with the upper extremities on a chair back.
More to come next week!
Posted 04/23/2013
If you’ve ever watched a swim meet, before every race the starter announces: “Swimmers, take your mark…”. Each swimmer then reaches down to the block to get ready to dive, or curls up if they are doing backstroke to get ready to explode into their race. They are putting their body into a starting position. In my last 2 blogs I discussed this interesting creature that we see that lives on land and thrives in water called a swimmer. I outlined different demands placed on a swimmers body based on the activity that they do, as well as the patterns and postures that are affected by those demands as well as the demands of just being a human. The next question is what do we do about it? Where do we start? How do we take our mark to get ready to explode?
As we look at the effects that swimming has on a human body, which is designed for walking and running, and add the demands that we all have as asymmetrical humans, I see a few important things that need to be addressed. From my perspective as a PT utilizing the science of Postural Restoration®, swimmers need (among other things):
a. Balanced airflow and chest wall movement in all directions
b. Increased strength of hamstrings and abdominals to decrease extension tendencies (they may have different needs on each side of the body)
c. Increased strength of glutes, lower traps, triceps, serratus anterior and rotator cuff muscles (subscapularis in particular) to counteract this very strong pattern developing in swimmers (remember the 14,400+ reps of pulling each arm does each week)
d. A properly positioned and efficient diaphragm muscle for breathing
e. Flexibility in hip flexors, back extensors, chest, neck, and external rotator muscles
f. A high quality shampoo/conditioner to help with that straw-like hair
So how do we get there? As I look at that list every item either contributes to or is influenced by one main need. (FYI it is not letter f.) The number one need that swimmers (and humans) have is letter d. The properly positioned diaphragm is how we “take our mark.” Without a properly positioned diaphragm balanced airflow and chest wall (which directly influences our spine) movement is impossible. When extension tendencies are too high limited hamstring strength and abdominal strength makes properly positioning a diaphragm impossible. Improper chest wall, spine, and shoulder blade posture from the strong pattern which is due largely to imbalanced breathing mechanics, limits strength of glutes, lower traps, triceps, serratus anterior and rotator cuff muscles. Again those muscles need to be strong to avoid injury (or so the research tells us). Without the ability to breathe with a diaphragm in the proper position, increased demands are placed on hip flexors, back extensors, pectoral, and neck muscles for breathing and postural support and they will get tight.
Therefore the first thing I want to look at with a swimmer (human) is activities to enhance trunk flexion (back rounding) and trunk rotation with proper use of abdominals and BREATHING! Our swimmers must be able to fully exhale to get their bodies into a position where the spine and ribs and diaphragm are in an optimal position for efficient breathing and learn how to inhale from that state of flexion without going back into a state of extension. Remember that pattern of extension that we see in swimmers promotes back bending, rib(chest) hyper-inflation and poor diaphragm position. The first thing to break that pattern is to get rounded and air out. When I see someone the first thing I want to know is can they breathe. And not just breathe but can they fully exhale to get air out and put their diaphragm in a proper position and then use it to inhale without overusing neck or back (extension) muscles. I will have a swimmer sit on a 6-inch step, hug their knees to their chest as much as possible and see if they can blow up a balloon.
©Postural Restoration Institute 2013
(Hmmm… this kind of looks like a backstroke starting position)
If they have trouble either a) getting into that position, b) exhaling fully into the balloon, or c) inhaling fully without using their neck (shrugging shoulders) or back (straightening the spine rather than keeping it rounded) I know they have a breathing issue that needs to be addressed first. This activity may now become their first exercise to do. Once we have that down I know we have a diaphragm that can at least get to an optimal position so they can take their mark. I don’t know if they can swim yet, but now we can start to train and address the other issues as outlined above as long as we can keep the diaphragm in that optimal position. Now we can start to explode and swim.
We also may need to address any imbalances that we see to promote a more symmetrical system by checking to see if equal neck rotation, shoulder rotation and trunk rotation is possible. If there is an imbalance, the swimmer can’t blow that balloon up, or is struggling with an injury I would recommend consultation from a Hruska Clinic or PRI trained PT to develop a specific program for that swimmer. Feel free to contact me if you have any other questions.
Posted 04/15/2013
What an energizing week it has been with outstanding speakers at this year’s two-day Interdisciplinary Integration course sharing their expertise regarding how they integrate the science of PRI to improve athletic performance. I think it is commendable that the therapists at the Hruska Clinic support the professional development of not only other PTs but also professionals in other disciplines who can benefit from integrating PRI concepts into their practice.
Thanks to all of you who commented in person on my blogs. One PT asked me if I will pass the National Physical Therapy Examination after all the exposure I have had to PRI. Well, I certainly hope I will, and I did bring two study guides to Lincoln, but I confess that the best use I have found for them so far is to stand on them with my left foot to put myself in passive left AF IR…
Following are some thoughts I wanted to share after this week in the clinic:
• In a previous blog I presented information about the A-B-A and A-B-A-B single subject experimental designs. Continuing with this topic, if the second intervention tested is not the same as the first one, it would be labeled alphabetically and sequentially, i.e. A-B-A-C. For example, Ron and Dr. Heidi Wise tried two different lens modifications on a trial eyeglass frame for a runner with extensive right-sided pain. The patient was not able to center as well with the second lens change, and she noticed that her vision seemed to be “less 3D-esque” with the second change, so she was switched back to the first lens modification. Another example is that A-B-A-C testing could reveal that a patient has been given standing exercises too soon and needs to build additional control through exercises in other positions. Only through testing and retesting will clinicians know if treatment progression is appropriate.
• One PT told me that in her clinical practice the A-B design is more common, and she does not usually conduct the second “A” phase during which a patient would be retested after withdrawing or reversing the treatment. For those of you who may be wondering if you should be conducting the second “A” phase more often, remember that in making clinical decisions we are most interested in whether any improvement seen is due to the intervention alone or something else. Although the A-B single subject design is technically not as strong as the A-B-A design, evidence of the cause-effect relationship between the intervention and the outcome is still convincing when the change is immediate (which eliminates the possibility of a time effect) and large. How large is large? Therapists trained with the skills to know whether a PRI test is positive or negative or to identify differences from one side to the other can confidently determine when a change has taken place. Keep in mind that the fact that PRI therapists even bother to retest during the “B” phase differentiates them from many other therapists. Remember the first time you were astonished during a PRI course when someone was shown to be neutral after performing a repositioning exercise? Did you think the outcome was due to coincidence? You were witnessing an A-B design. Here is something else to think about: Are there any therapists outside the PRI world having these types of discussions? Wow!
• Following every supine unilateral manual technique they perform, the therapists at the Hruska Clinic hold the patient’s wrist or forearm with the elbow extended and move the upper extremity in several small circles in order to increase circulation after the technique.
• I really liked the way Jason simplified a concept for a patient to make it hit home. “If you loosen something up, you have to tighten something else.”
• Women with a history of an inguinal hernia during pregnancy are likely to have pelvic floor issues. It is important to ask about complications during pregnancy or delivery when taking the subjective history. For a patient who had recent multiple root canals on the left side of her mouth within a short period of time, it seemed obvious where the source of her left jaw, neck, and shoulder pain was coming from. However, we had to look beyond the obvious and address the ascending issues causing excessive forces through the teeth, including the consequences of a postpartum inguinal hernia and thyroid surgery that had weakened the digastrics. This case was a reminder that ascending issues may contribute to jaw symptoms.
• A corset may be used to provide a temporary reference center for patients who have difficulty achieving abdominal integration.
• An interesting variation of the Standing Serratus Squat is to incorporate trunk rotation by holding one forearm off the wall and then the other. The lower trapezius muscles will be working on both sides at the same time with ST open chain activation on one side and TS closed chain activation on the other.
• A neat trick to help patients understand pelvis rotation during a supine 90-90 hip shift is to place a yardstick across the ASISs so that the patient can see how the yardstick tilts with the pelvis rotation.
• What if a patient cannot feel a certain muscle during an exercise, but you know that it is engaged because you can palpate a contraction and the patient is using proper technique? Dr. Wise gave this assurance to a patient, that it is okay not to be able to feel it yet because the brain needs time to process the information as the muscle is activated and to know what to do with it. The patient cannot sense it yet because it does not have meaning or purpose, so it might take some time before the patient can feel it.
• Patients with a narrow heel can decrease heel slippage in their shoes by tying the shoes more snugly around the forefoot, not at the other end of the laces closest to the ankle.
• For patients with pelvic floor issues, it is especially important to know once they achieve a 2/5 score on the Hruska Adduction Lift Test where they feel it as they are raising the lower knee. For instance, a patient with stress incontinence seen this past week could feel her left adductor but not her left glute med. For her the Adduction Drop Test was negative bilaterally, and the Pelvic Ascension Drop Test was positive on the left.
• One of the exercises given to the previous patient described was the Standing Supported Left Posterior Outlet Inhibition. Since her posterior outlet was so tight, Lori wanted to increase the height of her left foot only slightly to avoid back pain, so she had the patient put her left foot on a folded towel. This wide surface might have allowed the patient to cheat with a foot and ankle strategy, so Lori compared the patient’s ability to feel the left adductor and left glute med with the left foot on the folded towel and with the left foot on a 3-inch wide block (which was narrower than her shoe). For this patient there was no difference, so the exercise should be just as effective on a folded towel.
• This same patient had difficulty feeling her left glute med engage during the Right Sidelying Supported Left Glute Med exercise until her starting position was changed with the left foot higher on the wall to shorten the muscle initially. Eventually she should be able to progress to starting with her left foot lower while still feeling the left glute med engage.
• She was also given the Right Sidelying Supported Hemi 90-90 with Left FA IR. An important verbal cue for her was to roll the left thigh in without rolling the left hip in (down and forward). Instead of lowering and raising the left leg multiple times, the patient was asked to hold the position for a modified version of the exercise.
Wishing all the clinicians in the reading audience a great week of evidence-based practice! 
Posted 04/09/2013
Do you know what this blue thing is? During the most recent Advanced Integration course, another course attendee and I were snooping around in the treatment rooms at the Hruska Clinic, and we saw this hanging on the wall. As we were scratching our heads and wondering what PRI technique this might be used for, the best idea that we could come up with was that perhaps this was something on which to rest the ischial tuberosities. When I told Dave this story, instead of laughing at me, he told me with tongue in cheek that it’s not a bad idea, but the position I was thinking of facilitates an anterior pelvic tilt, so really it would be better to place the pelvis facing the other direction. I could hardly suppress a giggle when I first saw Jason preparing to do some prone manual techniques on a patient, and he folded a pillow case over the hole to use this mysterious object as a stand alone face cradle with some pillows tucked under the patient’s trunk to prevent excessive extension. Go ahead, I won’t mind if you laugh at me!
Continuing with my weekly blog series during my clinical internship at the Hruska Clinic, here are some additional “secrets revealed” from this past week:
• If you do not have a set of stairs in your practice setting, you might have overlooked the Standing Supported Left AF IR with Resisted Right FA Abduction exercise because the pictures show this one being performed on stairs. It is listed in the Non-Manual Techniques CD under Standing Right Adductor Inhibition (#10), standing Left Gluteus Medius (#36), Standing Left Ischiocondylar Adductor (#20), and Standing Integration (#81), so it is an excellent example of how exercises on the new CDs may be found in multiple places to correlate with specific treatment strategies. This particular exercise actually only requires one step, and the hands or forearms may be supported on a table or similar surface instead of a railing. The exercise may be progressed by starting with a lower step or even a phone book and then advancing to a higher step while keeping the right foot close to the floor.
• An effective way to incorporate the preferences of patients into their plan of care is to ask which exercises from the previous session the patient liked. For instance, one patient did not like using balls or bands. Another patient preferred standing exercises. Some patients may like the exercises that allow them to feel certain muscles more so than other exercises. The therapist can build on the patient’s preferences to progress therapy and facilitate adherence to the home exercise program.
• It was an eye opener to see a competitive long distance runner who had difficulty with alternating reciprocal activity. He had been progressing with his PRI program but was still experiencing intermittent hamstring or quadriceps pain with running depending on the type of workout he was doing. During the gait analysis and supine Trunk Rotation Test he showed limited trunk rotation. He also had Hruska Adduction Lift Test scores of 3/5 bilaterally as well as a positive right Passive Abduction Raise Test. After performing the Standing Wall Supported Alternating Respiratory Reach without resistance, the right Passive Abduction Raise Test became negative. Then he ran back and forth through the parking lot with his usual running style, after which he returned to having a positive right Passive Abduction Raise. He ran through the parking lot again, this time with Lori coaching him to use his shoulders, not his arms, to lead the upper body motion to increase his trunk rotation. She retested his right Passive Abduction Raise, and his range of motion had increased again. She explained that limited trunk rotation causes the back to extend, so the pelvis will lock up. His treatment consisted of various activities to facilitate alternating reciprocal activity, including manual facilitation of the arm swing while the patient walked on the treadmill at one mile per hour with a slight incline. It was difficult for him to slow down like this. In addition, it was remarkable how the manual facilitation was similar to how I would assist some geriatric patients during my skilled nursing facility internship to improve their gait mechanics. By the way, an interesting use of the Schwinn Airdyne bicycle was to facilitate trunk rotation by having the patient stand in front facing the bike with his hands on the levers and moving them forward and back.
• Exercises performed in the supine 90-90 position tend to be easier than similar exercises in the supine hooklying position, which are easier than dropped hooklying exercises due to the length tension differences in the hamstrings.
• Sometimes a patient will require additional support during a standing exercise. For instance, the Standing Wall Supported Left Knee Flexion with Resisted Right Glute Max exercise may be performed with bilateral upper extremity support on a chair back to prevent trunk extension.
• How can a patient fasten simple tubing to a door to do resisted bilateral exercises at home such as the Standing Wall Supported Resisted Reach? Tie a bandanna so that it makes a loop, thread the tubing through the bandanna, and close the door with knot in the bandanna on the opposite side of the door frame from the tubing.
• Some of you may have heard Ron talk about his futile attempts in the past to cleanly dissect the diaphragm crura from the psoas because of the strong fascial continuity. I like to tell patients about how the diaphragm is connected to the femurs; thus, “breathing is walking, walking is breathing.” This important connection was displayed when the manual left AIC technique was performed on a 65-year-old patient who still has residual left-sided spasticity from a CVA at least 10 years ago. As her diaphragm lengthened with the increasing zone of apposition, her left hip flexed with an extended knee so that the patient was doing an involuntary straight leg raise while supine. Incredibly, as her system let go of its neuroreflexive tone after this technique was performed, the patient’s left elbow that had been fixed in flexion automatically extended fully.
• The Standing Supported Left Knee Flexion with Right Psoas and Iliacus and Right Trunk Rotation is becoming one of my favorite left gluteus medius exercises after Jason told one of our teenaged patients that he would be shaking during this exercise. Sure enough, the patient was shaking so much that Jason told him that it looked like there were jumping beans in his pants! So now I like to refer to it as the Jumping Bean Exercise.
• For those of you who have been interested in my comments about evidence-based practice, consider how researchers who conduct randomized controlled trials strive to enroll a homogeneous population of subjects with as little variability as possible by following stringent inclusion and exclusion criteria so that the study findings will be categorized as high quality evidence with statistically significant results. Unfortunately, this study design limits external validity so that it is often more difficult to generalize the results to the specific patients that clinicians treat. As I have noted this as a methodological weakness in many school assignments critiquing the quality of published research for physical therapy interventions, I have marveled at how PRI is an approach that is effective with a heterogeneous population of patients. The fact that PRI principles and techniques can be used with a wide variety of conditions in patients of all ages is what makes the PRI approach so powerful.
• I have enjoyed seeing what goes on behind the scenes at the clinic to support the educational component of the Postural Restoration Institute. When they are not treating patients, the therapists are replying to clinical questions sent through email or blog comments, researching information in preparation for future blogs, preparing a brochure for an educational booth at a running event, or consulting with each other about challenging patients. It was this type of consultation that led to the development of a couple of new exercises in response to the need for additional quadriceps inhibition by some patients. Ron will be talking about these exercises during the upcoming Interdisciplinary Integration course.
• Speaking of the course, a lot of work spanning over many weeks has gone into preparing for the best learning experience for attendees, so if you will be attending the course, be sure to thank the support staff for their efforts.
I hope to see some of you at the course!
Posted 04/02/2013
Sometimes when we have lived in one place for a while, we take things that are unique to that area for granted. I have discovered that during this time of year Nebraska is a gathering place for more than 80 percent of the world’s population of sandhill cranes. In Nebraska they gain about 20 percent of their body weight as they rest and refuel on their way to Canada, Alaska and Siberia from Mexico, Texas and New Mexico. The above photos are screenshots from the Rowe Sanctuary’s Crane Cam by the Platte River that I have been watching and listening to occasionally when I am at my computer. Some of the locals do not seem to be overly impressed by the cranes, but I am intrigued by them. Similarly, patients often ask me why I came all the way from Arizona to Lincoln, NE for an internship, so I explain to them what I think is so special about the Hruska Clinic. Like the cranes, time flies when I am here! Following are some “ah-ha moments” from my third week:
• I was puzzled by why the Left Sidelying Foot Toward Foot exercise was easier than the Left Sidelying Knee Toward Knee exercise for one patient. Jason explained that the knee toward knee exercise requires more left AF IR. With that exercise this particular patient was actually better able to adduct his left hip by starting with the knees even with each other rather than with his right knee shifted forward. For several patients it was demonstrated that their pain could be reproduced with the right knee shifted back, so in those cases the point was made that this would be an incorrect way to do the exercise.
• We often start focusing on supported standing activities by a patient’s second visit, approximately a week after the initial evaluation. Patients are able to perform upright exercises even if they have not yet attained at least a 3/5 score on the Hruska Adduction Lift Test as long as they are supported by a wall, a table, the back of a chair, etc. I had learned this from another clinical instructor, but Jason mentioned this might still be a sticking point for some therapists.
• An important piece of equipment is a set of stairs. If you have not done the Retro or Lateral Stairs exercises, try them – you’ll like them!
• Two sisters who were featured in the Impingement and Instability course returned 8 years after the videos shown in the course were recorded, and it was fascinating to see the differences in their movement patterns. One overuses her rectus femoris muscles and needs more hamstring activation, which was facilitated by asking her to sense her heels during gait and with her exercises. The other overuses her latissimus and psoas muscles and needs more abdominal and glute activation, which was facilitated by asking her to sense her arches. Both benefited from the Squatting Bar Reach, which inhibited the quads more for one sister and the lats more for the other. The sister who had more abdominal control was able to lean forward and drop the bar to do a reverse squat while the other one had trouble keeping the bar forward to stand from a squat. I am learning that exercises that are usually done unilaterally may sometimes be done bilaterally. For instance, the sister who needs more glute activation will be doing wall supported squats with resisted FA ER and sidelying exercises for the glutes bilaterally because she needs improved strength on both sides.
• I have commented in previous blogs about educating patients by giving them something (such as a reduction in pain or increase in range of motion), taking it away, and giving it back to them and also about using evidence-based practice to guide clinical decision making. It occurred to me this week that clinicians at the Hruska Clinic frequently use the A-B-A single subject experimental design not only to inform patients but also to build on their own clinical expertise. The findings are conclusive and convincing. In an A-B-A design a treatment variable is introduced and then withdrawn. During the first “A” phase a baseline measurement is taken. In the “B” phase an intervention is introduced, the patient is retested, and any changes in the dependent measure are noted. The strength of this type of research design lies in the second “A” phase, when the intervention is withdrawn. If the intervention leads to improvement with a return to baseline after it is withdrawn, one can conclude with a high degree of certainty that the intervention was the factor causing the change during the “B” phase. Importantly, the best control subject for each individual patient is himself or herself, so the internal validity of this design is strong. In contrast, randomized controlled trials for physical therapy interventions tend to be full of confounding factors that weaken internal validity, and they usually have external validity issues because there is never a group of subjects studied who are all exactly like the patient being treated. Since therapy sessions typically end with an intervention phase, the design could also be considered an A-B-A-B design if the dependent measure is tested again after the final intervention. There are countless examples of where this research design could be applied in daily PRI practice. Following are a few from this past week:
... For a patient with right anterior hip pain from an overactive right TFL, seated unresisted right hip active internal rotation with flexion reproduced the pain. When she shifted into left AF IR and manual resistance was provided to left hip adduction, the patient was able to internally rotate and flex her right hip without pain. When she shifted into right AF IR, the movement was painful again.
... One of the most dramatic examples of A-B-A testing occurred during a PRI Vision evaluation of a patient with right low back, right hip, and right great toe pain who wore contact lenses that put her in monovision correction so that she had distance vision with one eye and near vision with the other eye. Without binocularity the patient had lost alternating reciprocal function, so the patient was constantly centered over her right side. Immediately after taking out one contact lens, her low back pain decreased during walking. Right hip external rotation and right HG internal rotation range of motion both increased, and the Hruska Adduction Drop Test on the left and the Abduction Lift Test on the right became negative. As soon as she put the contact lens back in, all of those tests became positive again. Her treatment will include taking her out of monovision for at least part of the day. The patient had tears of joy when she realized that her chronic pain, stomach and dizziness problems, and potential need for a hip replacement were all related to her contact lens prescription.
... For a patient with low back pain and a left AIC pattern, both the Squatting Bar Reach alone and Right Sidelying Scissor Slide followed by the Left Sidelying Knee Toward Knee increased the Hruska Adduction Lift Test score from 1/5 to 2/5, but the score went back to 1/5 each time after the patient took a few steps.
... For a patient with a right TMCC and right BC pattern and left neck and jaw pain, placing a towel roll under her neck to facilitate OA extension while she was supine resulted in the right HG internal rotation test becoming negative. When the towel roll was removed and the patient was asked to bite down and swallow once, her right HG internal rotation test returned to being positive. For this same patient, placing a tongue depressor between her left upper and lower molars while she was standing decreased pain with neck rotation, and the pain returned when the tongue depressor was removed. When the patient sat with trunk extension, her pain increased, and when she sat with her left elbow pressed into her left thigh, the pain decreased. Pain with cervical rotation decreased during the standing supported passive left AF IR with right trunk rotation but increased when the exercise was performed on the other side.
• Even an A-B design can be informative.
... For the previous patient, facilitation of internal rotation of the ribs bilaterally upon exhalation decreased pain and increased range of motion with cervical rotation. Also, the patient’s upper and lower teeth made contact on both sides after her ribs were brought down, instead of only on one side as they had previously.
... For another patient, the same facilitation of rib internal rotation decreased her low back pain.
... A patient with a left AIC and right BC pattern took three breaths with Dave facilitating the zone of apposition of the diaphragm and internal rotation of her lower ribs on the left. Right HG internal rotation increased from 40 to 90 degrees, the straight leg raise on the left increased from 60 to 90 degrees, the right Hruska Adduction Lift Test improved from 1/5 to 2/5, and left hamstring strength increased.
• Perhaps the following case could be considered a B-A-B design. Torin saw a runner who was treated last year for left knee pain, and she returned last week with right knee pain. PRI testing showed that she had fallen back into a right BC and left AIC pattern with a pathological left hip. After performing the 90-90 Hip Shift with Right Rectus Femoris and Sartorius with the addition of a balloon, the patient was repositioned as demonstrated by the Straight Leg Raise, HG Internal Rotation, Adduction Drop, and Abduction Lift tests. The patient was unable to maintain neutrality after walking a few steps in shoes with poor support. What amazed me is that her PRI tests became negative again after she walked in a pair of PRI recommended shoes with a right arch pad without doing any additional exercises! Torin mentioned that this might not have happened had she not already experienced a neutral position and that she still needs to work on muscle control to maintain neutrality.
• The previous examples show that testing and retesting are essential for ruling in and ruling out causes of pain and dysfunctional movement. Another example of methodical assessment was demonstrated with a patient who was experiencing headaches with neck and back pain. Ron tested various combinations of having her wear either her original splint or a temporary Gelb splint substitute along with either the progressive lenses she was currently wearing or glasses adjusted to match a new prescription in order to determine that a new oral appliance and her current lens prescription along with PRI exercises to center her over her left side will be the best strategy to decrease her pain.
• Can you place your tongue on the last upper molars in back and move your jaw the opposite direction? I have been learning about the importance of being able to dissociate movements of the tongue and jaw. An interesting patient of Lori’s could not jump rope until the patient was able to move her tongue independently from her jaw.
• Speaking of the tongue, Lori’s verbal cue for exercises with a balloon is to put a “fat tongue” on the roof of the mouth during inhalation, not the tip of the tongue.
• By the way, if you have not taken the Cervical-Cranio-Mandibular Restoration course lately, the content now incorporates right TMCC pattern genioglossus recommendations with an increased appreciated for the tongue as a reference center that is important for integration.
• For the Standing Supported Bilateral IO/TA exercise, one variation is to have the patient’s forearms on the surface in front, instead of just the hands with extended elbows, to increase trunk flexion for patients who have difficulty engaging their abdominal muscles. The patient could also lift one forearm and then the other one while perceiving the abdominal contraction on each side.
• I have noticed the therapists at the Hruska Clinic spend a significant amount of time during an initial evaluation taking a subjective history and listening to their patients. The patient’s story along with the gait analysis provide at least as much information as the objective tests about what is contributing to a patient’s pain or dysfunction.
Hope this is helpful! More to come next week…
Posted 03/28/2013
In my last blog (Amphibians can be people too) I tried to describe an odd group of individuals with different needs and demands they place on their bodies…swimmers. By the end I hope this one fact wasn’t lost on anybody: Swimmers are in fact people. They are in fact still humans who need to breathe and walk and talk and deal with gravity and the “normal” world like all of us but for several hours a day they dive into near weightlessness and move themselves around with completely different muscles and movement patterns and reference centers than the rest of us do. I think that qualifies them as amphibians… who are people too. Now along with the straw-like appearance of their hair and the slight chlorine smell they may exude, they develop some different muscle patterns and imbalances than some of us do. My goal with this blog is to identify some swimming specific patterns as well as some human specific patterns. Once we know who we are dealing with, we can get better at treating and working with these unique people.
When swimmers spend such an extraordinary amount of time and repetition pulling themselves around with their arms in an environment that requires them to hold their breath with a limited demand from gravity they will undoubtedly develop some patterns. In particular swimmers tend to develop a pattern of extension and hyper-inflation. Huh? A swimmers body that is driven into extension and hyper-inflation will tend to have a few common themes:
a. Deep low backs (tight low back muscles)
b. Elevated ribs in the front
c. Rounded shoulders (from strong, tight pectoral and latissimus muscles, which are used for pulling) on a spine that is extending/backward bending)
d. Forward head postures (that develop to compensate for the above)
e. Weak glutes (due to deep backs and forward pelvises with strong, tight, hip flexors from kicking)
f. Hyperextended knees when on “dry land” (from the forward pelvis and weakness in the glutes)
These postural imbalances, which are causing or a result of a pattern of extension or hyperinflation, can lead to several potential muscle imbalances that we commonly see.
a. Strong, powerful latissimus muscles. This is necessary for swimming power but unfortunately can limit rib cage expansion and rotation of the trunk through increased back extension. Increased extension of the spine limits the joints ability to rotate.
b. Long, weak, improperly positioned intrascapular/scapular muscles that stabilize the shoulder blade (i.e. middle and lower traps and serratus anterior). These muscles, if weak, have been implicated in shoulder injury/impingement in numerous research studies. This single point is usually the only focus of rehabilitation programs for a swimmer.
c. Strong powerful hip flexors and back extensors from flutter/dolphin kicking that are also positionally strong from being in prone. When these muscles become imbalanced with abdominals and gluteals/hamstrings proper pelvic and spinal position is lost.
d. **Improperly positioned, inefficient diaphragm muscle (pulled up by ribs and down by hip flexors) that leads to poor rib expansion and overuse of neck muscles for rib cage support and breathing. This will restrict trunk and cervical (neck) rotation.
e. Improperly positioned and long abdominal muscles (specifically transverse abdominis and internal oblique) for rib and pelvis stability as well as for trunk rotation.
That’s a lot of great stuff to work on and it makes a lot of sense in terms of what we see when we look at swimmers and assess their needs and bodies. However getting back to the point I made at the very beginning of the blog: Swimmers are people too. So what does that mean? That means that they have to walk on land and breathe air most of the day. They also have a normal asymmetrical postural pattern of right sided dominance which is attributed to many things including organ asymmetry, neurological/brain dominance, and habitual daily activities to name a few. If you’ve read any of our other blogs I know this pattern has been identified and explained but if that doesn’t make sense I would just refer you to search the site and keep reading.
This typical HUMAN pattern encourages this SWIMMER extension pattern we talked about above to potentially be more evident on one side of the body compared to the other. This imbalance, and how we choose to compensate for it, will usually restrict neck and trunk rotation and breathing efficiency more on one side of the body than the other. This will need to be addressed in addition to the above general swimmers needs. This means that reciprocal and alternating (i.e. back and forth, right and left) activity is a must to maintain as much balance and symmetry as possible. This is especially important with breathing and more so for swimmers.
An easy tip that is a good place to start for all swimmers and especially young swimmers is to encourage bilateral or reciprocal breathing patterns as soon and as much as possible. What this means is that when swimming the freestyle or front crawl swimmers should breathe every 3 or 5 arm strokes to alternate the side toward which they rotate to breathe. Swimmers will often have a side that they prefer to breathe to. However it is necessary to develop this reciprocal/alternating breathing pattern or you may develop a lot of the issues that we talked about above. This may include limited trunk or neck rotation to one side over the other and limited shoulder rotation on one side or the other. This will limit the swimmers ability to pull water as efficiently with one arm compared to the other. They may start to develop a rib flare on one side more than the other which will affect breathing efficiency. All of these will lead to potential muscle imbalances which increase the likelihood for shoulder or back pain on land or in water and potentially decreases the efficiency of your swimming strokes.
These postural and muscle imbalances need to be addressed as swimmers and as humans to maximize our ability to function normally whether we are swimming, walking, running, or breathing. In my next blog I hope to identify how we can use the science of Postural Restoration® to assess, treat and improve these imbalances for our swimming friends, no matter how bleached their hair may be. Please feel free to contact me if you have any questions or want more information.
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