Postural Restoration Pulling the rabbit out of the

Postural Restoration: Pulling the rabbit out of the hat as much as I can today and tomorrow Jason Hogan, PT, PRC

Objectives • Detect pathological vs non-pathological asymmetry • Gain an understanding on neutrality and breathing mechanics • Perform a test for system integration • Perform manual therapy treatment techniques for pathological breathing patterns and its effects • Understand the need for Non-manual therapy treatment techniques and be able to perform 1 -2

Postural Restoration Background • Postural Restoration Institute, 1999 • Ron Hruska, PT • Hruska Clinic (half dozen clinicians) • PRI (National Speakers) • Lincoln, NE • 3 Introductory Courses, 3 Advanced Courses • Affiliate Courses- Home Health, Baseball, Yoga, Exercise and Peds • 100+ Postural Restoration Certified Clinicians, PT’s, OT’s • 4 classes of Postural Restoration Trained- AT’s • Primary Research, Case Studies, Pilot Programs

Postural Restoration Beliefs Belief that the body is asymmetrical Belief in neutrality Belief in polyarticular myochains Belief in respiration Belief in system integration

Framework for PRI assessment: One test does not tell us everything, but helps triangulate primary issues that are emerging from this neuromusculo-masticatingalternating- reciprocal bipedal hominid

Comparisons to Traditional PT • Focus on pain reduction/elimination, return to function, establishing function, prevention • Primary charges Ther Ex, Gait, Neuro Re-Ed • Grounded in Neuro/Ortho/Kinesiology • No paradigm shift in how we understand the body • Know those attachments • Continue to use modalities

Contrasts to Traditional PT • Focus on diaphragm- continual evaluation of breathing mechanics • Algorithm to facilitation and inhibition in order for body to accept those changes • Triplanar movement is the focus ALWAYS • Cognitive awareness/ Neurological changes in cerebral cortex and cerebellum for long-term success • We are people divided into right and left • Testing and Assessments have different meaning • Hamstring Length versus Hamstring Tone • Ober’s Test versus Adduction Drop Test

The Reaping (minus the fight to death) • Everyone gets a different muscle group to be in charge of. • Think about the muscle and it’s attachments • When do we use this muscle • If this muscle is hypertonic, what muscles get affected • If this muscle is hypotonic, what muscles get affected • What surgeries happen around this muscle or to this muscle • What happens when this muscle is in prone, supine, sidelying • What is this muscle involvement in IAP, breathing

Postural Restoration Beliefs Belief that the body is asymmetrical Belief in neutrality Belief in polyarticular myochains Belief in respiration Belief in system integration

Belief in Asymmetry Preference versus Pathology • Eating a tough steak • Having to shift weight on one leg • One side is more ticklish • One side has a preference for turning our head for kissing • One side has a vagus nerve that has significantly more connections and a different function • Paraspinal activation • Preferred eye 11

James and Strokon (2003) Case of asymmetry gone too far!!!!!

Asymmetry: Try not to annoy your family/friends • Rib Cage/Rib Flares • Standing Shoulder Position • Too Many Toes Sign • Chin Deviation • What arm swings freely and which in stuck “Can the body mechanically and neurologically get into ideal positions to adapt to stress? ” Dr. Charlie Weingroff

Scapular Winging, 2 Different Reasons Burkhart et al “Sick Scapula”

Testing for Asymmetry!!!! • Myokinematic Tests (12) • Pelvis Tests (4) • Postural Respiration Tests (6) • CCMR (6) • Advanced Integration Tests (1)

Hruska Adduction Lift Test • Named by the leg on top. • Bottom ankle rolls up (1/5) • Bottom knee rolls off ground (Hold) 2/5 • Top leg brings pelvic off ground 3/5 • Top leg to neutral 4/5 • Top leg to adduction position 5/5

• Level 2: Rotate bottom knee up and off of mat LEVEL 1: Bottom ankle comes up to top knee Can they ER? ?

• Level 3: Bring pelvis off of ground. • Level 4: Top leg to neutral in frontal plane • Level 5: Adducted position (Top leg position)

Postural Restoration Beliefs Belief that the body is asymmetrical Belief in neutrality Belief in polyarticular myochains Belief in respiration Belief in system integration

The New Normal • Appreciate position of Right Diaphragm • Appreciate position of Left Diaphragm.

THE ZOA Breathe In= Ribs ER, Diaphram flattens, Post. Mediastinum expands, Lumbar Lordosis Thoracic Flattening, Decreased Zone of Apposition Breathe Out= Ribs IR, Diaphragm domes, Lumbar Flexion, Thoracic Flexion, Increased Zone of Apposition

SUSPENDERS HOLD UP PANTS AND FLEX AND EXTERNALLY ROTATE HIP Picture courtesy of Mary Bond Picture Courtesy of Kyndall Boyle

Breathing is a pressure thing • QUESTION BECOMES…what do we want our diaphragm to do. Stabilize or breathe or combo • The Answer: It depends on where at in the breathing cycle you are and the demands placed on it (Key---read the dang thing) • Dyssynchronism…the war for real estate • • • Left Anterior Interior Chain (L-AIC) Right Anterior Interior Chain (R-AIC) Right Brachial Chain (R-BC) Posterior Exterior Chain Right Temporal-Mandibular Cervical Chain

Start with the muscle you use the most • Quiet breathing • What draws the air in initially • What gets the air out • Maximum Breathing • What draws the air in even more…what needs to shut off…diaphragm draws in…What lets the air out…initial passive exhalation…what finished off the exhalation. • Is this person in a position to breathe without the baggage of other muscles? ? ? • Think about diagnoses that limit breathing mechanically • Kiddos with lumbar support (needed? ? ) • Why is utterance length limited? ?

Brachial Chain • Shoulder Internal Rotation (HGIR) • Watch for shoulder to roll up and off the table • Watch for goofy thoracic movement • Limited by pain- Questionable Sensitivity • Shoulder Flexion (HG Flexion) • Straight flexion with neutral spinal position • Limited by pain- Questionable Sensitivity

Apical Expansion Test (BC) • Hook lying supine • Breath in • Breathe out and add in thoracic flexion (bring ribs down on 1 -side) • Breathe in but keep compression on rib cage • Take interest in quality of ease of breath coming in on the opposite side. • EASY…excellent • PYIF…. not so excellent

Postural Restoration Beliefs Belief that the body is asymmetrical Belief in neutrality Belief in polyarticular myochains Belief in respiration Belief in system integration

Tight is tight for a reason, weak is weak for a reason 28

Can they walk? . . . I mean really walk? Can they adduct passively? (1 part of chain) Can they adduct actively? (1 part of chain) Can they internally rotate, adduct, extend? (closer) Can they internally rotate, adduct, extend in a gravity field while breathing not like a fox with his head in the snow? • Can they internally rotate, adduct, extend, breathe, while contralaterally externally rotating, abducting and flexing in a gravity field? • Can they IR, ADD, EXT, breathe while ER, ABD, Flex and doing the opposite on the thorax above? • Now…can they reverse it. • •

Orientation versus Compensation • Orientation of sternum to right results in • Left Diaphragm decreased ZOA • Left Triangularis Sterni (Transversus Thoracis) poor position to function • IO’s, EO’s, TA’s all messed up • Attach Arms • How does the scapular position have to compensate because of the change in orientation? ? ? ? ? • Right side- Pectorals versus Low Trap

Test for Polyarticular Myokinetic Chains • Hruska Abduction Lift Test (Level 0)

Level 1

Level 2

Level 3

Level 4

Level 5

Postural Restoration Beliefs Belief that the body is asymmetrical Belief in neutrality Belief in polyarticular myochains Belief in respiration Belief in system integration

Belief in System Integration ? ? (Ian Malcolm) ? ? 38

Can they walk? . . . I mean really walk? Can they adduct passively? Can they adduct actively? Can they internally rotate, adduct, extend in a gravity field while breathing not like a fox with his head in the snow? • Can they internally rotate, adduct, extend, breathe, while contralaterally externally rotating, abducting and flexing in a gravity field? • Can they IR, ADD, EXT, breathe while ER, ABD, Flex and doing the opposite on the thorax above? • Now…can they reverse it. • •

Hruska Alternating Reciprocal Rotation Test Level 0 Level 1 Level 2

Level 3 Level 4 Level 5

Brachial Chain plus Anterior Interior Chain plus Pelvic Chain • Left Sided Asymmetries Anterior Tilt Decreased Weight Less Tone in Adductor Calcaneal Eversion Knee Valgus HG-ER compensation Long & Weak ALAW • Right Sided Asymmetries Posterior Tilt Increased Weight More Tone in Adductor Calcaneal Inversion Knee Varus HG-IR compensation Short & Strong ALAW

Postural Restoration Beliefs Belief that the body is asymmetrical Belief in neutrality Belief in polyarticular myochains Belief in respiration Belief in system integration

Neutrality • What does it mean for your muscle to be in neutral? • Can it flex or extend equally • Can it abduct or adduct equally • Can it internally rotate or externally rotate equally • What is it’s orientation. • Shoulder rolling forward example • Can your muscle stay in neutral? • What internal issues could cause a loss of neutrality • What external issues could cause a loss of neutrality “What good is the warmth of summer, without the cold of winter to give it sweetness. --John Steinbeck

Pelvis Restoration/ PEC (Posterior Exterior Chain) • Functional Squat Test Level 1 Level 2 Level 3

Pelvis Restoration/ PEC • Level 4 Level 5

Name of this test • Can you concentrically control your pelvic floor while inhibiting your paraspinals while properly engaging gluteals while inhibiting your gastroc-soleus complex while being able to open up your posterior mediastinum for inhalation due to intestinal contents translating superiorly test.

Role of Manual Therapy • Manual Therapy is only used if Non-Manual Techniques are not effective • 1 st choice is an exercise that helps establish the cortical connections!!!!! • If there are limitations/restrictions that need mobilizations only then does manual therapy techniques enter into therapeutic regimen • Each Manual Therapy Technique has an end game • Follow-up with an exercise • Follow-up with another manual therapy technique

Guidelines for an Inhibition Clinician • Tell patient the reason for the intervention • Show position of hands • Describe in detail what to expect/ expectations for patient • Pain? ? • Stretching? ? • Breathing pattern? ? • BE AWARE OF YOUR TOUCH LEADING UP TO AND FOLLOWING INTERVENTION • Respond with feedback- always, always

Anterior Interior Chain Techniques • Left Anterior Interior Chain Technique • Left Hand is left sternum, 3 rd Digit is slightly below xiphoid process • Right hand is in apex of Lordosis • Breath In/Inspiration/Decreased ZOA • Right Hand---Think “Pull and Rotate” • Left Hand---Think “Hold • Breath Out/Expiration/Increased ZOA • Right Hand---Think “Hold…take up slack” • Left Hand---Think “Guide left ribs down---don’t push”

AIC • Sternal with Active Pelvic Tilt • Left Hand and/or Right Hand is on sternum (left side or central) • Breath In/Inspiration/Decreased ZOA • Patient performs posterior pelvic tilt, WATCH THE NECK • Breath Out/Expiration/Increased ZOA • “Guide sternum down…don’t push”

Left AIC Non-Manual Technique 90 -90 Hip Lift with Balloon

Brachial Chain • Superior T 4 • 1 Person, 2 Person • Left Hand---left sternum, 3 rd Digit is slightly below xiphoid process • Right hand---upper lateral (armpit) • Breath In/Inspiration/Decreased ZOA • Right Hand---Think “Guide Right chest up” • Left Hand---Think “Hold” • Breath Out/Expiration/Increased ZOA • Right Hand---Think “Hold Right side” • Left Hand---Think “Guide Left Sternum Down”

Brachial Chain • Infraclavicular Pump • 1 Person, 2 Person • Right Hand---Below Clavicle, and lower ribs • Left Hand---Below Clavicle, and lower ribs • Breath In/Inspiration/Decreased ZOA • Right Hand or Left Hand---Think “Guide alternating chest wall up, air into upper lobes and lower lobes” • Breath Out/Expiration/Increased ZOA • • ALTERNATING DEPRESSION R-L-R, L-R-L Right Hand---Think “Guide right ribs down” Left Hand---Think “Guide left ribs down” Alternate allowing lungs to fill up, finish with right filling

Brachial Chain • Sibson Fascial Release (Right) AKA Suprapleural Fascia • Sibson’s Fascia 4 inch by 2 inch where thoracic duct travels through fascia to empty into • C 7, T 1/ first rib/ Manubrium/ Cupula of Lung/ Fascia from scalenes and longus colii muscles • Right hand---Anterior Lateral Right Neck • Left hand---Right sternum • Breath In/Inspiration/Decreased ZOA • Right Hand---Think “Guide air in” • Left Hand---Think “Secure” • Breath Out/Expiration/Increased ZOA • Right Hand--Think “Secure what you have gained” • Left Hand--Think “Guide down”

Brachial Chain • Intercostal Release (Right) • Left Hand--- Right upper ribs with arm in a D 2 F pattern • Right Hand ---Right Lower Lateral Ribs • Breath In/Inspiration/Decreased ZOA • Right Hand---Think “Secure” • Left Hand---Think “Bring air in” • Breath Out/Expiration/Increased ZOA • Left Hand--Think “Secure” • Right Hand--Think “Guide down” • Rotate Knees to left

Right Brachial Chain. Standing Serratus Squat

Posterior Exterior Chain • Quadratus Lumborum Release (2 Person) (PRONE) • 1 st clinician: Left Hand-palm around lower ribs, forearm on lower ribs; Right hand- Right PSIS • 2 nd clinician: Left PSIS • Inhalation: Everybody Hold!!!, but allow air to enter into posterior mediastinum • Exhalation: Forearm goes anteriorly and cephalic, PSIS’s hold

PEC • Central Diaphragm • 3 Person • 1) Sternum position (1 or 2 hands) • 2) Right upper ribs, Right lower ribs • 3) Left upper ribs, Left Lower ribs Breath Out: Everybody, every hand guide down Breath In: Upper chest and sternum draws in air

Posterior Exterior Chain Non-Manual. Paraspinal Release with Left Hamstrings

Questions

Final Thoughts From David Rosenbaum’s It’s a Jungle in there. “The brains unruliness is not an inconvenient truth to be rued. Rather, it’s what gives rise to the mind as we experience it. ” David Rosenbaum

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