Posts by Louise Kelley

DPT, PRC

Providence, RI, one of the oldest cities in the U.S., is home to University Orthopedics. This PT clinic is GOAT, with large windows and water views on three sides, providing a parasympathetic balance to the focused attention on the impact of human asymmetry. It was wonderful to have professionals from different backgrounds (PT, PTA, ATC, CSCS, LMT) and skill sets come together to consider the profound impact of the diaphragm and rib cage on our movement. Following the discussion on the differences between optimal and sub-optimal breathing patterns, one attendee revealed that this was the first time in her life that she was able to inflate a balloon😊. The smaller-than-typical group size allowed for more one-on-one time in lab, ensuring attendees’ proficiency at carrying out objective tests and non-manual and manual techniques. Thank you to our models (Daniel Anthony, ATC; Kerri-Lynn Francis, LMT; Landa Pappas, PTA; Damion Perry, BS, CSCS; Joseph Robinson, ATC; and Maurice Sicard, ATC) and our reader, Stacey Brennan, MT, PTA – you greatly enhanced our understanding of course concepts. A huge thank you to our hosts at University Orthopedics (Dan Bien, PT, OCS, CSCS; Stacy Faiola, PT, CSCS; Kevin Mahoney, DPT, ATC; Dave Pezzullo, MS, PT, SCS, ATC; and Ed Wojciechowski, PT) for all of the work you put forth to provide a fantastic learning environment!

Posted September 4, 2018 at 7:05PM
Categories: Courses

The Sunshine State, and its urban gem, Miami, was the destination for the latest Postural Respiration course. Where else does one listen to Cuban salsa performed live outside the local grocery store? Thank you Cyndi Becker, MS, LAT,ATC, Lauren Reynolds, ATC, and Rodrigo Martinez, DAT, LAT, ATC for hosting at Florida International University, and giving this speaker a respite from the heat and humidity of DC (yes – Miami is more pleasant than DC in mid-July!).

For the majority of the class, this course was their first exposure to the paradigm-shifting tenets of PRI, supported by knowledge of human anatomy and by scientific literature that spans many decades and disciplines. We evaluated models from both the power point and in the flesh for evidence of sub-optimal breathing patterns and postural influences: thoracic flat backs, loss of apical expansion, belly and neck breathing, paradoxical breathing, and hyperventilation. We correlated these findings to our objective tests and patient-client complaints.

Participants learned the value of establishing and maintaining a left diaphragm ZOA, without which movement quality suffers and the ability to recover sufficiently is unlikely. Our discussion on non-manual techniques included their value in positively changing movement behavior through manipulating the nervous system and shifting the locus of control onto the individual. This group developed solid competency in performing and interpreting PRI objective tests, manual rib techniques, and effective cueing of non-manual techniques. You are ready to go forth and practice in a way that will be forever different than you used to!

Everyone facilitated the learning through their questions and comments. A special thank you to our models and readers: Amy Brown, DPT; Erik Kilstrup, CSCS; Rene LeBlanc, MPT, OCS; Rodrigo Martinez DAT, LAT, ATC; Julian Rivera, DPT, ATC, CSCS; Edwin Santiago, CPT, CES, PES, CS; Joseph Vuksanovic, LMT; and David Young, CSCS. A heartfelt “thank you” goes out to Megan Bollinger, DPT, PRC, for her thoughtful comments and great energy in lab. All of you Floridians have a superb mentor in your midst who would love to help you on your PRI journey.

Posted July 19, 2018 at 2:16PM
Categories: Courses

The spacious auditorium of St. Luke’s Hospital was the weekend home for 44 course attendees. The science of PRI continues to expand its reach to professionals from a variety of disciplines (PT, OT, PA, DC, PTA, ATC, and CSCS), with the lively Marquette University training staff well-represented.

This course dives right into discussion of our asymmetric diaphragm, creating lateralized patterns of air flow and obligatory patterns of movement, defined as the L AIC, and R BC. Attendees learned: the correlation between PRI tests and a person’s ventilatory – thus walking – strategy; how to identify joint pathology that can develop when the typical human patterns of the L AIC and R BC go awry; and how to identify pathological breathing strategies that develop from patterned position and activity – namely superior T4 and PEC syndromes.

Lab provided a kinesthetic and aural dimension to assessing activity of the left and right AIC, BC, and PEC, the quality of ventilation, and the degree of rib cage pliability/restriction. Our rib cages benefited from manual guidance to fully exhale and expand. Further lab was devoted to experiencing non-manual techniques that reinforce sensing of opposition muscles that shape the left diaphragm’s ZOA and shift our center of mass to the left while rotating the upper torso back to the right.

Special thanks to:

- The models who donated their bodies for the benefit of all: Cathy Curran, DPT, Audra Hawkins, PTA, Elizabeth Majszak, DPT, Steve Schmidt, DPT, and Brandon Yoder, ATC. ,

- Mary Jo Herrick and Selene Wang, DPT, of Aurora Healthcare, for the set-up, break-down, and keeping us hydrated and fed.

- Gabe Champeau, DPT, and Anita Panagiotis, MSPT, PRC for assisting during labs and sharing your clinical pearls.

Posted June 8, 2018 at 4:16PM
Categories: Courses

Philadelphia – “City of Champions” – provided good karma for the latest Postural Respiration course, hosted by Jon Herting, DPT, CSCS and Rob Rabena, MS, CSCS at Maplezone Sports Institute/The Training Room Physical Therapy. This was the first PRI course for half of the attendees. The class comprised a mix of PTs, PTAs, strength and conditioning specialists, coaches, massage therapists, and student PTs, with a range of experience and patient populations. Artem Imnadze, Nick Perugini, and Chris Stires, our students, confirmed that, still, there is virtually no discussion in the PT curriculum of the diaphragm’s functions. We addressed that short-coming through in-depth analysis of our lateralized diaphragm and its impact on human movement, physiology, and behavior. Ample time was devoted to testing and re-testing, following non-manual and manual techniques, to ascertain the each person’s degree of patterning and how challenged, or effective, they were in achieving tri-planar diaphragm position and activity. Participants learned that orthopedic dysfunction stems from our neurology and the patterned diaphragm. Therefore, breathing patterns and associated rib movement (or lack thereof) must be assessed and addressed to ensure recovery! Many mentioned they had “aha” moments throughout the course. Others had patients in mind that they planned to apply the material immediately. Thank you to Jon and Rob for hosting and to Jon and Frank Mallon, DPT, PRC, for your outstanding assistance with lab and clarifying concepts. Special thank you to Alfredo Aviles, NSCA-CPT, Ray Carr, DPT, Christopher Carroll, DPT, NCS, Justin DePermentier, DPT, ATC, Leor Giladi, DPT, CSCS, Tracey Emrey, MSPT, Michele Kersman, PTA, Nicole Ledbetter, LMT, Sheree McMullen, PTA, LMT, Jennifer Nieberlein, PT, ATC, Akil Piggott, DPT, Karen Vozzella, DPT, Michael Wehrhahn, DPT, CSCS, and Ryan Wolff, DPT for your insights, reading aloud to the group, modelling for lab, and setting up and taking down.

Posted April 12, 2018 at 8:31PM
Categories: Courses

Postural Respiration – Lima, OH (pronounced “Lie-ma”, like the bean). The course was hosted by Lima Memorial Wellness Center, inside the bright and spacious YMCA. We had clinicians from a range of fields (PT, PTA, OT, ATC, student, exercise physiologist, and chiropractor) and experience (from first course to twelfth). A good deal of time was dedicated to lab, where attendees gained solid familiarity on how to inhibit over-active chains of muscle through both manual and non-manual techniques. It was helpful to have seasoned PRI course-goers stepping in to offer their clinical pearls (Alex Maag, DPT, PRC; Mary Ann Arellano, PTA; Chris Fortman, PT; Melissa Miller, PTA; and Beth Trombley, DPT). Attendees learned the value of blowing up a balloon and filling a left posterior mediastinum and the meaning behind synchronize and separate to achieve optimal gait mechanics through obtaining, and maintaining, a L ZOA.

Thank you to our models John Hollenbacher, OTR/L and Lisa Overman, PTA, who kindly allowed us to evaluate their patterned bodies and who gamely performed non-manual techniques that would challenge any Olympian! Thank you also to our reader, Nancy Siatkosky, DPT, who was nearly flawless (good thing everyone was paying attention and didn't try releasing the subclavius with their derrier!). Many thanks to Alex Maag for fulfilling many roles, from lab assistant and A-V tech support to keeping this instructor well-fed, and to all of the clinicians of Lima Memorial Hospital: Ronnie Ballard, PTA; Cassie Frantz, DPT; Richard Garber, ATC; Mary Jump, PTA; Melissa Miller; Lena Moore, PTA; Nancy Siatkosky; Casey Siefker, PT; Jennifer Smith, PT; and Desiree Wallace, PTA. As someone who has hosted courses in the past, I know the effort that is put forth to make everyone comfortable – including the extra coffee on an oh-so-early Sunday morning😊 your hospitality was superb!

Posted March 14, 2018 at 3:08PM
Categories: Courses

The Olympic and Cascade Mountain ranges provided a spectacular back-drop for Postural Respiration, hosted by Erin Rajca, DPT, PRC, Betsy Baker-Bold, PT, PRC, and Leslie Kinoshita, all PTs with ATI Physical Therapy. The course kicked off with a discussion on the two respiratory diaphragms and how the right hemi-diaphragm over-powers the left, creating the lateralized, predictable patterns of breathing and movement present in us all. This segued into the symbiotic relationship between the hemi- diaphragms and ribs: i.e. well-positioned diaphragms allow rib movement, and proper rib movement/expansion helps to maintain diaphragm position to keep patterned movement in check. This concept was woven into defining the what, why, when, and how of inhibiting the L AIC and facilitating the R AIC to provide a foundation for synchronized movement of a thorax over a pelvis – i.e. early stance phase of gait. This synchronization provides the foundation for the subsequent separation of the thorax on the pelvis at mid to late stance. The end game: alternating, reciprocal – aka “tri-planar” --respiration and movement!

Responding to previous course feedback, a fair amount of time was devoted to practicing the nuances of both non-manual and manual techniques and where they fit into a patient’s/client’s program. Attendees were able to sense rib movement and air flow, in the roles of patient and practitioner, and to sense engagement of the muscles that oppose the patterns. Thank you to our models: Greg Lewerentz, Geneva Bender, Jeremy Kirschner, and Maryann Kuchera (and to Erin Krekling for being a ready and willing back-up). Each of these individuals enabled the class to experience the unique challenges of stiff rib cages, belly breathing tendencies, and/or superior T4 syndrome.

Thank you to all participants this weekend – you were a spirited, engaging group with thoughtful questions and feedback!

Posted October 19, 2017 at 9:29PM
Categories: Courses

Coastal Ortho, in Brunswick, ME, was the site of the most recent Postural Restoration course. Located 45 min from “America’s Foodiest Small Town” of Portland, the gorgeous, state-of-the-art facility provided a terrific lunch-time setting, with the Atlantic Ocean a mere few blocks away. As always, the weekend focused on the lateralized differences between a right and left pelvis and rib cage, created by the asymmetric diaphragm. Also emphasized were the prevalence and consequences of thoracic extension and how the loss of ZOA reduces movement variability (“#longevity matters”). Much time was spent observing a variety of breathing strategies, what to do about a therapist-patient size mismatch, and sensing rib cage movement and air flow (Springfield College students Declan Morrisey and Clayton Lent gamely performed their first-ever mobilizations). Thank you to the Coastal Ortho team for hosting: Brian Bisson, Kelsey Bisson, Kate Baughman, Lisa Burdick, Beth Carlton, Amanda Cleaves, Sarah, Coughlin, Dan Doherty, Amy Farrell, Rebecca Marple, Katie McCarthy, Pat Nelson, Shawn Paquette, Craig Priestly, and Amin Saab. Kudos to our reader, Wendy Lessard and to the superb lab assistants Anita Furbush, PT, PRC and Michael Mullin, PTA, PRC, who provided clarity and depth to the discussions with their clinical expertise.

Posted October 3, 2017 at 2:06PM

This past weekend’s Postural Respiration was held at Quinnipiac University, at the Frank Netter School of Medicine, where many of his iconic, albeit symmetrical, medical illustrations line the hallways. We had a lively mix of PTs, ATCs, and SCSs, most of whom had at least some exposure to the PRI paradigm and were eager to develop a greater understanding of the science. Mainstay characters, such as little Russian boy, Charlie, Owen, the Chain Smoker, and pec-man illustrated how loss of alternating, reciprocal movement, from improper training, incomplete integration of primitive reflexes, or habitual, uni-dimensional postures contribute to a vicious cycle of compensated, sub-optimal breathing in an attempt to get air, leading to even greater compromise in breathing. Much time was devoted to getting hands on rib cages, securing a zone on the left, and guiding air flow to allow participants to feel more optimal respiration.
Special thanks to Brijesh Patel for hosting and keeping everyone well-fed; models Brian Wolfe, James Pasquin, Matt Herhal, Andrea Goldberg, and Vasilina Sosnina-Waldron; reader Nicholas Buchta; and the A-list lab assistants Donna Behr and Miguel Aragoncillo who provided superb clinical pearls.

Posted June 30, 2017 at 1:39PM

NYC – Concrete jungle, where dreams are made of and where heavy down pours and cancelled flights couldn’t keep us away.  It was a weekend full of feeling ribs and moving air in “warehouse chic” Finish Line Physical Therapy.

Thank you to Mike Conlon, Emmi Aguillard, Raechel Bugner, Andrew Fenack, Alicia Ferriere, Samantha Jacobsen, Alision McGinnis, Morgan Mowers, and Mike Riccardi for being gracious hosts and serving Ron his favorite pretzel snacks.   The class, a mix of PTs, PTAs, ATCs, and CSCSs, included a wide range of PRI exposure, with almost half taking a PRI course for the first time and a third who had three or more PRI courses under their belt. 

Right off the bat, Ron introduced the PRI paradigm-shifting tenet of two diaphragms, which carried us into in-depth discussions on: 1. importance of right apical and left posterior mediastinum expansion for good weight shifting and rotation; 2. how breathing habit shapes the thoracic spine and rib cage and how thoracic spine and rib cage movement and position affect breath quality; 3. how the all-mighty right diaphragm lateralizes us to the right, perpetuating the L AIC/R BC pattern of movement; and 4. The opposition muscles that attain, and maintain, a L zone of apposition.  Finally, we learned a new balloon-blowing strategy, herein dubbed “The Patrick”, in which you jiggle and wobble your rib cage to inflate the balloon.

Ron and I extend a special thank you to Bethany Delman and Nancy Brown, our lab models, and to Miguel Aragoncillo and Josh Lebow for your excellent insights in lab. 

Posted May 10, 2017 at 3:59PM

A Recent Email question (from 2008) on understanding psoas relationships with the diaphragm in general: 

“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?”

Ron’s response: “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 (is agonistic to) the left leaflet of the diaphragm; and the left psoas is agonistic 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, it’s 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.”

Here are my initial thoughts on the email question: The R hemi-diaphragm doesn’t need help in its respiratory role.  It already has plenty of help in the form of a liver below, larger, thicker crura and central tendon, and better abdominal opposition to maintain its domed positon.  Its dominant respiratory activity contributes to chronic tension, not only of the abdominals, intercostals, and lats on the R side, but also of the muscles associated with the R brachial chain.  This is the crux of the reduced R intercostal and apical expansion.  So can activation of a R psoas change this, and can it improve R apical expansion?  Yes, indirectly, with a host of other muscles, but not by “activating a right diaphragm”.

Ron’s response was to acknowledge that a relationship does exist between the psoas and both the ipsilateral and contralateral hemi-diaphragm.  He states: “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).”

However, it’s not as simple as flexing your R hip.  To clarify:

In our conversation about this email, Ron reminded me that occasionally a R psoas, not just a L psoas, can get hypertonic in a L AIC pattern. How?

Our brain simply wants fulfillment of L spinal rotation, and these 2 muscles may work together in an attempt in to satisfy the brain’s “request”. 

How is it that the R psoas and L diaphragm (and L psoas and R diaphragm) work harmoniously, if not through “tightly woven attachments”, as is the case ipsilaterally?

A vector force, through fascial connections overlying the anterior vertebral bodies, creates this contralateral influence.

Is this right psoas-left leaflet connection in the transverse plane significant?

No, they are ineffectual in achieving L lower spinal rotation. Why?  Because of the L side’s hyperinflated state and externally rotated ribs.  There is air in the way!

(another consideration:  Because of the orientation of the facets, minimal transverse rotation occurs through the lumbar spine.  That area moves more in the sagittal and frontal planes.  Therefore, it is the psoas’ frontal plane influence that is more significant when it comes to breathing and walking.)

Could a right psoas assist a L diaphragm with drawing air into the R apical chamber? 

Indirectly, yes, along with a host of other muscles.  However, certain conditions must first be met.

James Anderson states: “Limited influence of L crura in the transverse plane, lack of well-established L ZOA, and lack of L abdominal opposition, all complement R lumbar spine orientation.”

The R diaphragm partners with its abdominal wall to maintain its position as a powerful muscle of respiration and rib orientation.

If the R psoas becomes busy trying to rotate the lower spine to the L with a L hemi-diaphragm that has a smaller, shallower crura and with L ribs that are in ER, it will need L IOs/TAs to provide the needed pull on the L lower ribs for thoracic flexion and doming of the diaphragm.  Additionally, L abdominal wall opposition creates intra-abdominal pressure and, therefore, a counter-force to the descending diaphragm.   As long as those L ribs remain in ER, the L hemi-diaphragm will remain in a tonic state, influencing the tonicity so often seen in the L psoas.  In summary, when the L hemi-diaphragm contracts unopposed by the L abdominals, our upper body mass tends to shift to the L and, therefore, force us to compensate by spending more time and placing more weight on the R lower extremity in stance or L swing phases of gait, creating and perpetuating dysynchrony!

So while the R psoas can exert some degree of sagittal plane and L transverse plane motion, it serves us better in the frontal  plane, creating convexity at the lumbar spine to provide fulcrum from which L thoracic abduction can occur.   L thoracic abduction is a necessary movement pattern for maintenance of L ZOA and to provide the L hemi-diaphragm with a fulcrum (L hip) that is now situated directly below.  With an established L ZOA through L IO/TA activation, the L hemi-diaphragm can do its job of breathing – creating pressure differentials that allow us to manage gravity and walk, efficiently – with the least amount of force and torque.  This is how a R psoas indirectly enhances R apical expansion, along with many other muscles not mentioned in this orchestrated movement pattern.

 L IOs/TAs and a domed L hemi-diaphragm are the principle lower spinal/sacral/pelvic rotators to the L. 

Finally, why is it that the L hemi-diaphragm, not the R, expands the R intercostal and apical regions?

Rib position determines a hemi-diaphragm’s respiratory direction of flow.  When ribs are IRd on one side, they are ERd on the other.  IRd ribs assist the hemi-diaphragm with achieving and maintaining its ZOA to effectively draw air in.  Therefore, sufficient activity of the IOs/TAs, via their attachments to the ribs and their influence on intra-abdominal pressure, is a requirement for that hemi-diaphragm’s ZOA. 

IRd ribs don’t allow for much expansion. ERd ribs do. Therefore, once sufficient L IO/TA activity exists, creating L IRd ribs and a ZOA that is now effective for ventilation, the L hemi-diaphragm can draw air into the R apical chest wall, assisting with, and maintaining, its ERd ribs. Remember, when ribs are IRd on one side and ERd on the other, the thorax is positioned in ipsi-lateral abduction and contra-lateral rotation. Hence, 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.”

We have 117 techniques in the standing integration section to teach us to get the R side to let go and to get the L side of rib cage to IR, highlighting the importance of L IO/TA activation to establish L hemi-diaphragm ZOA and restore its respiratory role.

Posted April 18, 2017 at 7:16PM
Categories: Website Courses Science

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