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...