“Its Monday Morning, I’ve just taken my first PRI course and now what do I do and where do I start?”
If you have just taken your first PRI course and you feel a bit overloaded with information, don’t feel alone. The first time I went to a PRI course, can I tell you I was intrigued, stunned and just a bit intimidated all at the same time? I didn’t know what the heck I was doing so on Monday morning I had a bunch of people blowing up balloons! (Take the Postural Respiration course and you will know what I mean!)
In fact, the entire body of knowledge of PRI can feel like one big elephant you are trying to digest. And you know the old question, how do you eat an elephant? One bite at a time!
The first thing to do is what you learn in every course and that is to breathe and relax. There is a lot information here that needs to sink in over time and you won’t get it all the first time. No one that has taken one of these courses has gotten it all the first time but if a door is opened to your curiosity and caring to learn more you are definitely on the right track!
What helped me in my overwhelm was to create a picture in my mind of some of the basics. For instance, we aren’t symmetrical and never will be but the point is to manage asymmetries and get neutral. Then, have a simple picture anatomically of the basic asymmetries left and right side and how they affect position and posture thru polyarticular chains. Remember how the diaphragm is the key player and you have a simple way to describe what you are doing to yourself, patients or clients. They will be impressed by just a short, and I mean short, description of their anatomy and how it affects them.
On Monday morning, pick one person you feel comfortable with to experiment on. If you have a colleague that has gone to a course practice with them. Tell your patient that you just got out of a course and you want to try some powerful tools with them. If you took a Myokinematics course, practice an abduction drop test and show them one basic exercise. It is best that you practice that exercise yourself and continue to practice PRI tests and exercises yourself, so you know what it feels like and what to feel when you are in position for facilitation and inhibition. PRI works best when we are managing our own asymmetries!
Immediately you have knowledge and application of assessment and corrective positioning that is really sophisticated and you have just scratched the surface. You can build on this by learning a new assessment or two with a new corrective position every day.
Have your manual close. Refer to it, study it and get a more detailed picture in your mind of how the human body works and how you can be more effective. This is called building a body of knowledge and it doesn’t happen overnight but you can get results and get excited with just the basics and build on top of them.
If you went to a live seminar, order the home study course and review it a few times. If you got a home course, go to a live course to interact with the instructor and fellow students. Pack a bunch of questions in your bag when you go! If you get a little frustrated with all the information and it doesn’t make sense all at once, then you are a normal human being! Hang in there. The good news is that becoming more skilled and competent is satisfying and meaningful and that building a body of knowledge and expanding what you know is just plain fun!
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.
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…
I just recently finished reading "It's a Jungle In There" by David Rosenbaum. This cognitive psychology overview, with a Darwinian perspective, touched on 'perceiving more than is really there'. Phenomena often reflect "top-down" processing. The term refers to high-level interpretation biasing perception, so perception is not just dictated by immediate sensory data or "bottom-up" processing, but is also shaped by expectations. Over-competition and under-cooperation among relevant neural representatives can bias perception.
The last course I taught in Richmond, VA was Cervical-Cranio-Mandibular Restoration, and it was attended by a number of 'neural representatives' that were once "bottom-up" processors and are now "top-down" perceivers. I really enjoyed their cooperation and non-competitive communication!
There is now a Postural Restoration Google Group! We welcome fellow PRI practitioners to join! The purpose of this group is to facilitate the exchange of PRI based concepts, ask advice about challenging cases, post important research articles, and create discussion regarding any PRI ideas or techniques that you care to share.
Examples of some topics:
Heart Rate Variability Analysis, Thoracic Mobilization, and Autonomic Dysfunction
Pesky Patho PECs and Clinical Pearls for the Art of Inhibition and Facilitation
To join, email HeatherCarrDPT@gmail.com. She will then send you an invitation to accept.
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.
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...
I recently found myself, once again, defending the wonderful science that Ron and everyone at the Institute have been so generous to share with us all. In this instance, the forum was a Facebook conversation (most of which can be viewed here) where PRC candidates Bill Hartman and Zac Cupples, along with myself, expressed our experiences with PRI to a group of contraians and skeptics.
As a means to provide closure, I constructed a response which provides a synopsis of therapeutic intervention as well as an explanation of how PRI prinicples help me intervene. After a wealth of positive feedback via social media, Jen and Ron asked me to share it here for the brilliant community of PRI clinicians. The response begins in the quoted text below.
Thanks to all of you for being such an inspiration and for positively influencing my education as a physical therapist.
"It's becoming increasingly clear that the path to system variability and pain-free movement is gated by neuroception (i.e. limbic threat appraisal) and autonomic nervous system output. And its these two properties of the nervous system which govern the effects of the innumerable methodologies therapists use to expunge system rigidity.
Autonomous of discipline or method, clinicians intervene at the level of the receptor (rods, otoliths, mechanoreceptors, etc.), engendering unique signal transduction and transmission into a sea of equal status patterns which participate in collective summing within the brain.
We'd hope our therapeutic inputs contribute to a modification in the perceptive capabilities of the patient, though (as we all know) this is not always the case. Some inputs never reach the level of perception while others exceed the adaptive capacity of an already rigid system, perpetuating chronic limbic hijack and sympathetic dominance.
But a positive change in perception opens valuable cortical real estate for neuroplastic remapping via graded exposure, which is the substrate for system variability. This is really the goal of any physical therapy intervention.
So, how do we know we're dealing with a rigid system in the first place? And furthermore, how can we evaluate the efficacy of our inputs with respect to restoring system variability?
Beyond many other "systems" I've experimented with, PRI seems to provide the most cogent answers to the above questions. And it's the "umbrella" which explains, to me, why other methods work.
What PRI provides is a means to identify a predictable pattern of ANS-mediated anti-gravitational motor output for a collection of systems held in some degree of rigidity. The perspective they bestow is quite comprehensive; PRI is a unified system respective of ALL sensory inputs capable of influencing reticular output (mechanoreception, vision, audition, etc.).
But woven through its complexities, their simple orthopedic testing and treatment algorithms provide a reliable means to assess this aberrant output, as well as evaluate the systemic and perceptual perturbations that might follow any therapeutic intervention (PRI, Mulligan, Maitland, MDT, ART, etc).
Because interventions can be both synergistic or antagonistic to the pattern PRI presents, utilizing a withdrawal A-B-A study design during a treatment session (with the patient functioning as their own control) upholds an element of internal validity beyond what other systems might be able to provide. I'd argue this makes PRI a powerful adjunct to anything you're already doing, as we scrounge for external validity in a increasingly heterogeneous population.
PRI treatment aims to recapture reciprocal and alternating movement in three planes across the three girdles of the body. And PRI is never about fixing posture - it's about restoring system balance, variability, and adaptive potential."
For those in Colorado interested in discussing PRI, the Colorado PRC therapists Lisa Kelly, Scott Kosola, and Craig Depperschmidt are planning a quarterly informal meeting to talk PRI. Our first one will be Saturday, May 31st 2p.m. at The Point Sports Medicine and Rehab. Address is 6801 W. 20th St., Suite 203 Greeley, CO. Lisa, Scott, and Craig will be leading topic discussion but the meeting will be informal and open to the needs and interests of the group. Email Craig at email@example.com with any questions!
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!
Check on the new recent email that has been posted, where James Anderson answers a course attendees questions on the FA Range of Motion charts in the Myokinematic Restoration course manual.
CLICK HERE to read Jame's response, and to check out all the recent email questions in the archives!