Posts by Louise Kelley

DPT, PRC

Fort Collins, CO: The wide expanses of meadows and trails, fresh mountain air, and the Rocky Mountains – merely a stone’s throw away – provide an irresistible playground for movement. Did you know that movement starts at the thorax? The thorax is the first and foremost body region to assess and treat in our patients-clients, regardless of symptoms. The most recent rendition of Postural Respiration, hosted by Rebound Sports and Physical Therapy, explored why this is true. The group included a large cohort of physical therapists joined by two PT students, an athletic trainer, PTA, occupational therapist, chiropractor, and pulmonologist.

Postural Respiration includes in-depth discussions on the form and function of the left and right hemi-diaphragm, reflected in:
-    inefficient breathing strategies, such as belly and neck breathing and breath holding.
-    inefficient walking patterns, such as lack of arm swing, leaning to one side, early heel rise, and waddling.
-    forward head posture, straight spines, and rib flares.

Like the other two primary courses, Postural Respiration offers an algorithm to guide the clinician and provide the when, how, and why of treatment progression.  We spent significant lab time performing and interpreting tests and practicing non-manual and manual techniques to achieve a level of competence come Monday morning, with its real-world patients. Comments from the class after the techniques: “I feel more grounded.” “My movement is more fluid.” “My neck tension is gone.”

Thank you to those who elevated the learning experience for all by willing to be models for assessments and treatments: Sarah Awe, PTA; Tyler Fosdick, DPT; Daryl Hobbs, DC; Ambrey Holliday, MSPT; Annyce Mayer, MD; Michele Munsil, DPT; Alexandra Nachtman, DPT; Tara Rorvig, ATC; and Marisa Vargas, DPT.

Thank you to the staff at Rebound Sports and Physical Therapy, for all of the work you put in to host this course: Sarah Awe; Emily Clark, MSPT; Tyler Fosdick; Jason Grissom, DPT; Ambrey Holliday; Crissy Ott, MSPT; Brad Ott, MSPT; Elyse Prescott, DPT; Kevin Rhodes, OTR, CHT; Amber Schwarting, DPT; and Karen Stillahn, DPT, PRC. Karen, your insights and expertise during lab was invaluable and so appreciated!   

Finally, thank you to Craig, Abby, and Daisy Depperschmidt for your warm hospitality. I thoroughly enjoyed hanging out with the three of you and sharing stories over breakfast and dinner.  You made me feel so welcome!

Posted October 10, 2023 at 6:35PM
Categories: Courses Science

I had the great fortune to present Cervical Revolution to an in-person and virtual group, hailing from 10 countries.  This course takes the concept of humans’ neurological proclivity for right stance at the pelvis and thorax and carries it up to the neck, teeth, and cranium.
As we know from previous courses, right stance dominance creates complex neuromuscular patterned positions and movements and is heavily influenced by gravity, respiration, and overactive chains of muscles.  We introduced a new chain, the temporo-mandibular cervical chain (the TMCC), which, you guessed it, is over-referenced on the right.

The course was greatly enhanced by:
-    Our in-person attendees, who were instrumental in demonstration of objective tests and treatment techniques:  Lisa Bartels, DPT, PRC; Andrew Consbruck, DPT, PRC; Nate Dickes, PT; Eric Pinkall, PT, PRC; and Kurt Van Kulken, ATC.
-    Kelli Reilly, MSPT; Timothy McVaney, DDS; Nancy Wehner, BSDH, COM for sharing clinical observations and expertise.
-    Our virtual attendees, for thought-provoking questions and insights, most notably Evan Condry, PT; Alex de la Paz, PT; Christopher Lamb, NASM CPT; Peien Lu, PT; Donne Ordile, PT; Locatelli Rao, DPT, PRC; Laura Regan, DPT; and Alek Skorupa, LMT.  To those of you watching in the wee hours of the morning or late at night, thank you for hanging in there and participating in lab.
-    Jen Platt, DPT, PRC, for orchestrating everything this weekend – virtual views, answering questions, providing nourishment, and more.

Attendees gained an appreciation for the brain’s need to sense a new floor – at the occiput on atlas (OA) articulation.  This articulation, when in its proper position, allows the head to remain in equilibrium with the spine below.  Imbalanced left to right sensory processing and motor output occurs when the OA articulation is better sensed and over-referenced on the right side. The very health of the brain may be in peril when we over-reference our right sides too much and for too long.  For example, a “twist” results in the neck, compromising a vital opening for brain: the foramen magnum, which houses the brainstem and “cisterns” for cerebral spinal fluid, bathing and protecting our nervous tissue.

The OA compression-decompression (known as OA flexion and OA extension, respectively) reverberates into the cranium at the junction where the occiput meets the sphenoid.  This critical junction enables vector forces through the cranium to be distributed to the remaining paired bones of the cranium.  When over-referenced on the right, two commonly seen conditions develop at the sphenoid-occipital junction, or synchondrosis: left side-bending and its pathological cousin, right torsion.  

These cranial positions, maintained by the Right TMCC, place the paired temporal bones in a patterned position.  The temporal bones mirror the ilia of the pelvis and should exhibit alternating internal and external rotation, depending on the leg you’re standing on.  The other half of temporal-mandibular joint (TMJ), the mandible, too, is directed and held in patterned state.  Without temporal alternating activity, structures within the temporal bones (think mid-brain and vestibular) are deprived of their necessary compression-decompression cycles that are so vital for nerve function.  Our mandibles may lose their ability to move side to side, a prerequisite for upright left to right shifting when, say, walking.  In addition, alignment of our upper and lower teeth becomes skewed over time and may lead to mal-occlusions, such as cross-bites and open bites, and TMJ disc derangements.  One can now appreciate the need for dental collaboration and intra-oral splints to assist the process of restoring alternating tri-planar movement of the cervical spine (30-30-30) and temporal bones and a sense of alternating floors at the OA articulation.  Doing so promotes nervous system health, resolution of symptoms, and efficient functional movement.

I capped off my weekend in Lincoln with Jen Platt and her family with an awesome experience at the U. of Nebraska Women’s volleyball game. You know you’re in for a treat if 92,000+ fans pack the stadium, as they did the previous week.  Put this on your to-do list the next time you’re in Lincoln on game day.  Hopefully you can snag a ticket!

Posted September 21, 2023 at 3:48PM
Categories: Courses Science

An enjoyable weekend was spent with a fantastic, energetic group at Thrive Proactive Health in Virgina Beach. Thrive has hosted numerous PRI courses, and its clinicians were ready to take their PRI knowledge up a notch with Cervical Revolution.

As in every PRI course, the concepts in Cervical Revolution are rooted in our neurological propensity to be oriented in right stance, a dilemma that manifests itself in the neck and cranium. Our right atlas, in particular, remains oriented over the right foot and under a right occiput, creating a highly influential “floor” for the cranium. A cervical pattern is established, resulting in tonicity of a chain of muscles known as the temporal mandibular cervical chain, or TMCC. Much like the left AIC and right BC chains, the right TMCC may become over-referenced during upright function. And just like the sacrum in the pelvis and the sternum in the thorax, our third “S” bone, the sphenoid, may become patterned in its position and movement.

The effects can be profound. Consider the vital openings associated with the neck: the foramen magnum and the pharynx. Malposition and narrowing of these openings effect nervous system and visual and vestibular function, cerebral spinal fluid flow, circulation to, and drainage of, the brain, and airway, swallow, speech, and chewing patterns.

We practiced objective tests, unique to this course, that assess loss of cervical and mandibular motion and the likely presence of two common cranial positions (called “lesions” by osteopaths): left sidebending and right torsion. We presented multiple photos of faces, with facial characteristics that reflect these two positions, and discussed the impact of these positions on symptoms that we commonly treat: neck pain, headaches, dizziness, and TMJ pain and dysfunction.

To prepare for their Monday morning patient/client, participants experienced techniques designed to restore cervical neutrality, a sense of the left OA floor, lateral shifting of the mandible, alternating cranial expansion of the temporal bones, and sphenoid orientation.

Finally, we discussed patient examples in which “orthotics for the mouth” -- dental splints – were combined with a PRI program, resulting in beautiful therapeutic outcomes. I hope that those attendees who haven’t yet established a relationship with a dentist are now inspired to make that happen. Mark Ragusa, you have Howard Hindin, DDS, right in your neighborhood.

Laurie Johnson, see you on the next zoom course😊 Mark Pedersen, wishing you all the best as you begin your physical therapy studies. Takumi Sakabe, safe travels back to Japan. You have a wonderful PRI cohort that will take you in with open arms. Thank you to everyone in attendance for your questions and insights and to the clinicians of Thrive for hosting and keeping the discussion light and lively!

Posted May 26, 2023 at 1:57PM
Categories: Courses Science

The ENT Institute of Atlanta played host to the most recent Postural Respiration. This course encouraged attendees to look below the head and neck for “bottom-up” influences on the conditions you treat. What do hip pathology, low back pain, headaches, and TMD have in common? A thoracic diaphragm that is patterned in its position and activity.

We discussed how the static asymmetries of our torso lead to overactive chains of muscle below the diaphragm (anterior interior chain and posterior exterior chain) and above the diaphragm (brachial chain). These chains create dynamic patterns of breathing that become entrained in our nervous system and that can restrict healthy alternating, reciprocal movement when upright. Numerous videos were presented that reflect how patterned breathing influences walking: poor posterior right arm swing, reduced thorax rotation and center of mass shift onto the left leg, and waddling, to name a few. Our stronger, better leveraged right diaphragm creates twist and torsion of the airway which, in turn, promotes inefficient strategies to pull air in, including belly and neck breathing, with their associated forward head posture, hyperinflation, and overly extended thoracic spine and rib cage. Neurologically-driven patterns of airflow define how we sense ourselves in the space around us, how we move through it, and our vulnerability to pain and injury.  

Many thanks to Kaitlin Blankenship, ATC; Jose Crespo, PT; Mischelle Hardwick, PT; Allison Robbins, PT; Tre Tate, CPT; and Adria Wofford, PT for volunteering to model the tests and techniques.    

Kristen Spencer, PT, PRC, was invaluable in assisting with lab and adding clarity to questions and concepts.  

The practitioners at ENT Institute did an awesome job of accommodating us guests: Jose; Ann Gerber, PT; Jennifer Hansen, PTA; Mischell; Jennifer Harrell, PT; Deisy Nunez Aguirre, PT; Allison; Olivia Terrell, PT; and Cristen Walker, PTA.   

I hope you get the chance to host again. If so, Cervical Revolution would be a natural fit for your caseload.  You will learn about the influences of an additional chain of muscles, the temporal mandibular cervical chain. You will gain an understanding of how the concepts of Postural Respiration and patterned air flow apply to the cervical spine and cranial patterns and their potential to create malocclusion, TMJ dysfunction, headaches, and visual-vestibular disturbances, all of which you routinely address in the clinic.

Posted March 23, 2023 at 3:32PM
Categories: Courses Science

I felt right at home with the clinicians at Finish Line Physical Therapy, all seasoned runners. Photos of their and their patients’ running accomplishments, all smiles at the completion of a race, adorn the space – and make for the perfect back-drop to discuss the impact of undesirable airflow patterns, habitual use of accessory muscles of breathing, and a restricted diaphragm on movement.


Asymmetry is the rule of the body and brain. As such, humans, by design, exhibit a right-sided preference, which is reinforced by a culture that favors sitting and a lifestyle made easier by technology. The result is a form of “hemi-neglect” of left sided muscles of grounding – hamstrings, gluts, and abdominals – needed for weight-shifting. Rib cages remain under the influence of muscles that don’t promote alternating internal and external rotation and the associated sense of expansion and recoil. The result is a form of left or bilateral COPD, with its distinctive hyperinflation.

   
Stiff, patterned rib cages and abdominal oblique disuse cause the diaphragm to undergo twist and torsion that, in many cases, cannot get out of. This twist of our respiratory system is a significant mechanism underlying the many syndromes and injuries that we confront in the clinic.


Many thanks to our weekend avatars, whose willingness to demonstrate and receive techniques enabled us all to better understand PRI concepts: Patrick Cronin, PT; Laura Gibbons, PT; Laura Loftus; Iris Platt, PT; RikkiLynn Shields. Thank you Yohei Takada, PT, PRC and Andrew Xenophontos, CSCS, PRT for your tremendous help in lab, coaching the attendees in the nuances of the manual and non-manual techniques, allowing them to experience the power and influence of these techniques on the neuro-muscular system. Finally, thank you to the physical therapists at Finish Line PT for being gracious hosts: Mandy “I WILL blow up a balloon” Fox, Connor Hesselbirg, Jaclyn Massi, Ryan Matisko, Timothy Waanders, and Jimmy Williams.

 
Finish Line PT is a clinic for runners and triathletes, people who strive to be their best selves. To all of the course attendees, I hope the material you learned this weekend will help take you to new heights in your careers and shift your stride to a new way of looking at, and improving, movement.  

Posted March 9, 2023 at 3:37PM
Categories: Courses Science

Enveloped by palm trees and the salt-water aroma of the Atlantic Ocean is a gem of a clinic: Arise Center for Athletic Development, our host for Postural Respiration.
Arise was filled to capacity, evidence of the thirst for PRI in the Sunshine State. With her wedding just days away, Tia Moir was determined to put aside her pre-wedding jitters and focus instead on growing her understanding of PRI concepts. Tia, I hope your wedding day was glorious!


Postural Respiration lays the groundwork for concepts that are reinforced in every one of the Institute’s courses: the neurology of movement and the role of the thoracic diaphragm on patterned, habitual activity and our nervous system’s state of tension and twist present in all our patients-clients. Through lecture and lab, attendees gained a thorough understanding of, and experienced within themselves, the power of the hemi-diaphragm’s most important characteristic: its zone of apposition. Loss of the left hemi-diaphragm’s ZOA initiates deleterious air flow patterns and is the underpinning of movement dysfunction. Attendees learned how to coach their patients-clients through numerous non-manual techniques that place an individual in novel, biased positions and challenge the nervous system to disengage old movement patterns and replace them with healthy, efficient ones.
Post-lab comments included: “My left side feels heavier.”  “My back tension is gone.”  “I can breathe deeply again.”


It was our good fortune to have in class Amy Brown, PT, PRC. Amy assisted in lab and shared her clinical perspectives throughout the weekend. Amy is well-versed in the PRI approach and is a great resource for the Floridian contingents, especially those starting their PRI journey.


Many thanks to the team at Arise:  David Donatucci, Austin Hetzer, Jen Lewis, Mickey Massucci, and Ahmed Rashwan.  You were instrumental in providing an atmosphere of comfort with good energy and flow.  
Thank you to our models, who greatly enhanced the learning for all:  Joi Dupre, Rogelio Govea, Amy Haddad, Hugh Pun, Ahmed Rashwan, Rosaline Riuz-Go, and Brandon Van Kempen.   
Arise will host Myokinematics next year.  Faculty member Kasey Ratliff will bring her PRI prowess and clinical versatility to strengthen your PRI knowledge and understanding of how the neuromusculoskeletal system really works.

Posted November 16, 2022 at 7:46PM
Categories: Courses Science

What was I doing in a bank vault all weekend, admiring larger-than-life action shots of Steph Curry, Lindsey Vonn, Misty Copeland, and Michael Phelps? Presenting Postural Respiration to a fantastic group of clinicians, of course!   Baltimore’s iconic Bank of America building has been refurbished and now houses FX Studios and the Under Armour Performance Center.

Half the class were newcomers to the science of PRI. The science asks these newcomers to, for a moment, put down your beveled scrapers and dry needling filaments. Pause a moment before you mobilize a joint or release fascia. Put aside any preoccupation with extremity joints and focus your attention, instead, on where movement begins: the thorax.

 

Throughout the weekend, we cited research from luminaries, such as Kapandji, Hodges, Wallden, Chaitow, and DeTroyer, to support the concepts covered in this course:  
-    Diaphragm zone of apposition (thank you Nate Taylor for reminding us of its importance).
-    Respiratory state of twist that is the precursor to habitual, reflexive patterns of movement and the musculoskeletal pain syndromes that we treat.
-    Paradoxical, inefficient breathing that impacts and reflects chest wall and pleura restrictions.
-    How to restore pelvic and rib cage position, through techniques that reinforce abdominal oblique activity and chest wall expansion.
-    How to retrain previously inhibited, inaccessible muscles to promote new, healthy patterns of movement to better sense the environment they’re in and efficiently move through it.

Lab sessions provided application of the above concepts and allowed participants to discover how the “patient-client” in front of them displayed biased sense of air flow and biased orientation of their chest wall. They learned how to coach their partner to novel positions that retrain the nervous system and promote a new, desirable sense of compression and decompression. All participants sensed freedom from habitual movement patterns.

 

I can’t help but think that the athletes adorning the walls, all of whom reached the pinnacle of their respective careers and displayed remarkable longevity, mastered the art of air flow, pressure regulation, and chest wall movement variability during both performance and during rest and recovery. This is what we should strive for in all of our patients-clients.

A huge “thank you” to the professionals of FX Physical Therapy for hosting: Matt Bordeau, Sean Jones, Christine Spurlock, Morgan Taylor, Jennifer Tola, and Mary Williams.  

Thank you also to Miranda Stauffer, Danelle Warner, Amy Morris, Kenya Lewis, Dylan Irving, Jackie De Conti, and Kenneth Scott for your willingness to be the models for tests and techniques.  

I hope all attendees left the course feeling empowered to immediately apply the tests and techniques and begin to weave this new, powerful paradigm, one patient-client at a time, into your approach to care. And to the Newbies:  Welcome to PRI Nation!

Posted October 4, 2022 at 6:38PM
Categories: Courses Techniques Science

As always, I enjoyed my weekend at the home of PRI in Lincoln, NE to present Postural Respiration to an in-person and virtual group with my friend and colleague Jen Platt, PT, PRC. Although virtual learning can be a challenging format to gauge the interest and energy of attendees, such was not the case with this group, who offered many questions, insightful comments, and thumbs-up to relay to this instructor “Yes, we got this concept.” Our in-person squad was instrumental in helping illustrate concepts, serving as models for the PRI tests and non-manual and manual techniques. A huge thank you to our models Hailey Beasley, PTA, Jason Bushie, ATC, Ellen Kindelsperger, DC, and Tasuku Kurane, ATC, for your willingness to express what you sensed during and following each technique.

As anyone who has taken Postural Respiration knows, there is a great deal of research and conceptual material to sift through, contemplate, and consider. What is quickly understood, by practitioners both new to the science and with numerous courses under their belt, is that the PRI approach can be applied to any and all patients/clients. Its techniques offer a game-changing approach to care. The many lab sessions provide experiential learning and an opportunity to practice how to present and explain the how and why of assessment and treatment with the “patient” in front of you.

It is not enough to simply move air in and out of the thorax. All humans accomplish this, one way or another, to stay alive. It is the ability to direct that bolus of air into different regions of the thorax that determines how variable and efficient our movements may be, how we experience the environment around us, and how well we rest at night. This ability becomes compromised the longer we are constrained by the human’s natural asymmetries that become reinforced by static postures and repetitive activities of daily life. Ensuring the balanced roles of the left and right hemi-diaphragm, that of both posture and respiration, requires an understanding of how to maintain each diaphragm’s zone of apposition, inhibit deleterious muscle over-activity, and re-establish a sense of expansion of the posterior mediastinum from which new, healthier patterns of movement can emerge. These foundational concepts are what Postural Respiration is all about.

Thank you to all attendees for taking time out of your summer to challenge your thinking and grow professionally. It was nice to see many newcomers to the science as well as veterans such as Brittany LaFountaine, DPT, PRC, and Joe Siracusano, DPT. I encourage all of you to keep asking questions and seeking answers, through the PRI website resources, dialogue with fellow clinicians, PRIVY, and the many courses that PRI has to offer

Posted August 24, 2022 at 8:51PM
Categories: Courses Techniques Science

I really enjoyed presenting Postural Respiration at the very place that PRI began – Lincoln, NE – to a hybrid group of enthusiastic and inquisitive in-person and virtual attendees.
We spent the weekend learning about the influences of the left AIC, right BC, and bilateral PEC patterned overactivity on hemi-chest compression, air flow, and movement. Our most primal movement pattern, respiration, is directly reflected in how we move our bodies in space. The quality, efficiency, fluidity of our walking is directly impacted by where air is directed in the chambers of our thorax.  The numerous videos and photos, presented throughout the weekend, provided stark examples of the deleterious effects of patterned respiratory mechanics on upright posture and movement.

Through lab breakouts, the in-person attendees helped me talk through and demonstrate how to determine if, and how much, a person is being driven by polyarticular muscle overactivity that prevents proper compression and decompression of our systems for healthy movement and physiology.

 This being Lincoln, NE, and not Providence, RI, balloons were back in business, allowing attendees on both sides of the screen to experience eccentric and concentric abdominal contraction and air flow into previously compressed regions of the thorax.
We discussed how the ability of the right 1st rib to move reciprocally is key to enabling the remaining ribs to reciprocally move. Its ability to raise and lower for compression/decompression of the apical chest wall is compromised with overactive scalenes that encourages the subclavius to join the party.  With this disruption in hemi-rib uniform movement at rest, we become stuck in a respiratory state of twist that an individual doesn’t know how to get out of. Hemi-rib uniform movement at rest is a prerequisite for calming the nervous system, so that we can truly rest at night.

Thank you for the many questions to clarify concepts for all attendees. I think I speak for everyone when I say the additional insights that many of you provided, especially in response to the non-manual techniques, were helpful and appreciated. Finally, a big thank you to RJ Hruska for deftly handling the A-V while answering questions and keeping this instructor hydrated and on schedule!

Posted May 31, 2022 at 4:55PM
Categories: Science Courses

The clinicians of Lancaster General Hospital are pros at hosting PRI courses. Last weekend’s Postural Respiration course was their seventh. This instructor had moments of déjà vu, since LGH was the location of the first PRI course I attended, back in 2007. Two participants, Deborah Schrodi, PT, and Cathy Ingram, PT, were also in attendance at that very course 15 years ago! The surrounding Amish community, who eschew automation, provided an interesting contrast to our modern way of life and its epidemics of myopia, asthma, and loss of movement variability. These modern ills can be traced, by-and-large, to technological “advancements”.   

Underscoring the Institute’s interdisciplinary mindset, the class was comprised of a mix of clinicians, including physical therapists, physical therapy assistants, athletic trainers, massage therapists, and personal trainers. Many were new to the science, while others had multiple PRI courses under their belt.

 

The Institute continually works to update course material, adding research articles and patient photos and videos to illustrate and support course concepts. Our left and right hemi-diaphragms are different in size and have differences in abdominal support.  This “static asymmetry” creates a teeter-totter effect within our body, keeping us reflexively alive and providing a starting point from which to move. When this teeter-totter situation reaches a tipping point, we have only a “totter”. The right side remains pinned-down, grounded, and compressed. The left side is held aloft, remaining ungrounded and decompressed. We cannot thrive in this state.

   

Our patterned, maladaptive hemi-diaphragm position and activity has consequences on movement, physiology, and behavior. Humans require oscillating compression and decompression of our lungs and rib cage to provide movement and ensure the health of our tissues, most notably the nervous system. An outward sign of this lack of oscillation is breathing pattern dysfunction, such as belly breathing, chest wall elevation, and superior T4 syndrome, the underpinnings of many of the syndromes that we treat.

Postural Respiration is a lab-heavy, hands-on course, better taken live, if possible. Participants came away proficient in performing and interpreting PRI’s objective tests to identify overactive left IAC, right BC, and B PEC chains of muscles and the pesky superior T4 syndrome. These patterns need to be inhibited so that we can efficiently and effectively inhabit the environment around us, without deleterious effects on our neuromusculoskeletal system.

A huge shout out to Frank Mallon, DPT, PRC, owner of Renaissance Physical Therapy in near-by Philly. Your expertise and instruction on the nuances of the Institute’s non-manual and manual techniques was invaluable!

     

Thank you to all who asked questions and provided clinical comments, keeping the energy level high. Thank you to our models, who enhanced the learning experience: Kirsten Ditzler, DPT; Kelly Faller, PTA; Eileen Herman, PT; Isha Mody, PT; Joesph Newton-Pretko, DPT; Kyle Price, PT; Lori Shearer, PTA and Michael Polejav, PT who all helped facilitate our learning.

Thank you to the LGH clinicians for your efforts in set-up and clean-up. I appreciated the opportunity to present this material at the place where my PRI journey started.

Posted May 5, 2022 at 9:06PM
Categories: Clinicians Courses Science
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