Posts by Jesse Ham

CMP, PRC, PRI Faculty Member

Lori and I enjoyed our time and journey teaching Pelvis Restoration with the group of movement enthusiasts at Rebound Sports Physical Therapy this past weekend.  An engaging and fun group whose particular attention to clinical and on-field applications of pelvic inlet and outlet position will be applied readily. Inhibition and detecting the best time to inhibit based on special test findings was a good topic covered in detail.  Thanks again to all who attended and helped make this weekend a snowy, enjoyable event for all!


Posted February 25, 2015 at 11:14PM
Categories: Courses

Hello triplanar thinkers!

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

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

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

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

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

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

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

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

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

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

Jess

Posted July 13, 2014 at 3:03PM
Categories: Clinicians

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…

Posted June 2, 2014 at 3:15PM
Categories: Clinicians

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...

Posted May 10, 2014 at 6:29PM
Categories: Clinicians

Hey everyone, thought I’d drop in a brief example of how a PRI paradigm helps me in clinic.

In my practice, I treat about 25% postoperative patients.  Yesterday, I began a session with a patient who is seven weeks status post right ACLR who I had been predominantly treating "per protocol guidelines" with the patient improving functionally using that approach.  However, yesterday the patient presented subjective symptoms similar to those of pes anserine bursitis in the affected knee--she could not straighten her knee very well and noted end range pain, had difficulty with normal stride length on the right and could not stand on her affected right leg without severe pain in the anteromedial right knee.

Objective findings showed straight leg raise 65°on the right (60 left) adduction drop test positive bilaterally, Hruska adduction lift test 1/5 bilaterally and a 20° lack of end range knee extension on the right.  Patient had palpable tenderness over distal aspects of the semitendinosus and semimembranosus, noted comparable sign with resisted knee flexion. There was palpable tenderness over pes anserine bursa of the proximal tibia and noted swelling in the same area.

After repositioning the patient, she had 5° lack of extension, or 15° improvement, 85 degrees of SLR, the ability to stand and walk on the right knee without pain and significantly increased step and stride length functionally.  Patient was then able to perform functional closed-chain strengthening activities without pain and will now be progressed through a PEC algorithm of treatment integrated with her postoperative protocol. 

Though I begin implementing PRI concepts of respecting position, triplanar functional control and utilizing polyarticular muscle chains that affect postoperative care at different times dependent upon the patient, the apt time presented itself to me with this patient at the start of this session. 

Attaining neutral position of a pelvis gave functionally “longer” hamstring musculature, taking the strain off of the distal attachment sites of the medial hamstrings, thus decreasing pain, increasing functional end-range extension ROM and immediately allowing me to progress with rehabilitation of her right knee s/p ACLR.  In this case, PRI principles and techniques allowed me to progress a patient s/p ACLR more quickly than with traditional orthopedic rehab methods alone and will improve not only the patient’s recovery from surgery, but her quality of movement and function during and after recovery.  A fun session for both therapist and patient!
 

Posted May 2, 2014 at 4:55AM
Categories: Clinicians

"What Introductory PRI Course Should I Take First?"

Hello PRI world of thinkers and learners!  Jesse Ham here, chiming in on a topic that has been and will continue to be a worth-while discussion:  What is the best way to get clinicians engaged into looking at movement through a PRI lens?  Or, put another way, what PRI introductory course will be the best to take first?  There really isn’t a right or wrong answer.  This is my impression from my experience personally as a clinician and from listenting to others' responses after they have taken various courses.

If we were all blessed with Ron Hruska’s ability to shift paradigms, take in seemingly limitless amounts of information, integrate it together and apply what we learned, then there would be a simple solution.   We would all take a week-long PRI Introductory course called Postural Myokinematic-Pelvis-Respiration Restoration.   Not only does this title not fit on the front of a manual, it’s a mouthful to pronounce, much less digest and apply all at once.

Even if we could get a week off consecutively to attend such a course, most of us will be on “new information maximum” somewhere between the afternoon of the first day and mid-morning of the second day.   After taking my first Myokinematic Restoration Course "four score and seven-plus years ago," I recall the need to work with it on many patients, review the manual, PRI blogs and emails, and just process the base concepts for quite some time.  So, since the best introductory course is a bit bulky, I pose a feasible strategy for where to begin taking the three introductory courses, Postural Respiration, Pelvis Restoration and Myokinematic Restoration.

To do so, I will take a small tangent here:  Before I was aware of this Institute, in fact before I went to PT school,  I was aware that clinicians struggled mightily treating IS (Ilio-Sacral) joint dysfunction.  There were seemingly as many special tests and strategies for treating this joint as there were clinicians and instructors.  Some said the IS joint didn’t move at all, others said it needed to be manually mobilized if it wasn't functioning properly.  Every static and dynamic imaging study had been done, with conclusions that gave very little insight from a clinician’s standpoint.  I studied Cyriax and all the derivatives up to Mulligan's work presently, I studied Gary Gray’s viewpoint.  I reviewed the various clinicians’ work who were, in part, responsible for muscle energy techniques to continually self-mobilize the ilium on the sacrum.  There are many more who contributed to this IS joint's body of research and treatment techniques, I have merely brushed over a few.  The take home here is that after PT school and several years of practice, I had no definitive answers as to how to affect the position of this joint and maintain that effect for my patients as they moved in a triplanar world of forces.

Then I started to take on the world of PRI and its viewpoint as to how to effect this IS joint's position.  As I became more adept at utilizing PRI concepts, I was far more successful at treating maladies related to IS dysfunction.  But there were still some patients that I had to constantly reposition, those who were never free of a relatively constant "HEP."  Far too many (~20-25%) of these patterned IS dysfunction patients were “better” but not well.  They still needed consistent intervention, were not integrated and therefore I was not happy.  Loose ends and unanswered questions still bothered me for some of my IS patients.

Along came Lori Thomsen and later Jen Poulin teaching Pelvis Restoration.  Mind you, the concepts of pelvis position are woven into Postural Respiration and Myokinematic Restoration, and this discussion does not apply strictly to IS dysfunction--that was just one of my conundrum diagnoses that I use as an example here.  But from my experience I was not as effective at those “tough ones” that we all have until I began to appreciate the position of an inlet and an outlet of a pelvis.  Specifically, how that inlet and outlet position enables me to integrate a thorax with lower extremities optimally to allow a patient to attain reciprocal, alternating function and live their lives free from the bondage of perpetual, unsustainable diagnosis-specific exercises to maintain their function.

The above is my abbreviated rationale to the question I posed for the title of this piece.  For those of you who skipped to the end of the book and like short answers, mine is this:

If I had it to do again, I’d take Pelvis Restoration first, followed relatively closely by Myokinematic Restoration and Postural Respiration.

Thanks for taking the time to review this blog.  I will enjoy reading your experiences and story about what introductory worked well for each of you!

Posted February 14, 2014 at 3:47AM
Categories: Courses
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