The Hruska Clinic Integrator


  • Check out this video of Lori describing what neutrality is and what it really means for your program. Neutrality is the starting line, not the finish line!

  • New PRIME Patient Care Coordinator

    The Hruska Clinic is proud to be announcing the addition of Megan King to our staff as our dedicated PRIME Patient Care Coordinator. To learn more about Megan and our PRIME program click HERE.

  • Read an blog on our PRIME website from Torin outlining the difference between clarity and perspective and what that means for us as humans who want to move. I good general perspective on why we may have or struggle with issues that don't get better.

  • Read the last part of the PRIME Case study outlining a return trip (Episode III) to Lincoln from our patient after spending several months working with a local PT (Episode II). Read what progress was made and how adjustments in the program needed to be made as layers of patterned activity were peeled back. This return adjustment is often the most powerful in fully getting to the point of disengaging form a PT program.

  • We are pleased to have University of Rhode Island PT student Karl Busch here in the clinic doing a clinical internship. Here is a guest blog from him outlining something he's noticed in his first few weeks in the clinic. Here he talks about "Keeping Things Simple". Enjoy.

  • Read the first part in a case study series outlining how our PRIME program works, and works best when integration happens here in Lincoln and with those not in Lincoln.

  • Some things we've learned about Interdisciplinary Integration over the last 18 months since starting PRIME.

  • Here's a link to a video from Lori Thomsen, from her recent Interdisciplinary inservice on Patterns, Feet and Footwear showing the impact shoes can have on patterned movement.

  • Hear Lori talk about the difference between right and left hip flexors, their influences on and by breathing/diaphragm function and position, and how they can be treated differently once you understand this issue.

  • Listen to Lori discuss proper pelvis and rib cage position to safely and effectively perform planking-type activities.

  • Video blog from Lori Thomsen on the purpose and technique for PRI squatting, why we look at it and what it tells up about transitioning to loaded squatting as part of a strength program.

  • If you are considering or have been recommended to undergo any type of vision related treatment (strong glasses, vision therapy or training etc.) or have any concerns about your child's visual skills for reading or upright activity please read this great write up form Caiti (with assist to Dr. Heidi Wise) on what else may be playing a role and how our PTs may be able to assist.

  • Here are the links to all of our #MySoreSpot series blogs from the entire staff. Feel free to share with friends if they are complaining about their sore spots. We may be able to help explain #WhyItHurts.

  • "If they can help me, they can help anybody." -Megan

    Here is the link to the final Meet Megan blog

  • Takuto Kondo and Kan Sugiyama traveled from Japan to take part in the Hruska Clinic's™ Clinical Integration Mentorship Program. Takuto discusses his experience at the Hruska Clinic™.

  • Here is the next part in our Meet Megan series. Hear Megan and Mike describe their experience and feelings after initiating treatment for Megan's dysautonomia/POTS.

  • Here is the second video in a series introducing you to a patient of the Hruska Clinic and PRIME. In this video hear from Megan's husband Mike as he describes what their life was like prior to coming to the clinic.

  • The last of our #MySoreSpot series looks at the very important left hamstring muscle. Dave does a great job explaining and demonstrating potentially #WhyYouHurt

  • Click here to Meet Megan who is a patient of the Hruska Clinic and PRIME program and learn about her background and history dealing with POTS and who she was prior to coming to the Hruska Clinic. Stay tuned for more videos as we get to know more about Megan and her recovery.

  • Jason discusses how the hip is often the overlooked source of knee pain.

  • As part of our #MySoreSpot blog following the Lincoln Marathon Expo listen to Torin discuss what may be influencing why your left ankle might be hurting when you run (or walk).

  • Caiti describes #WhyYouHurt in your lower back as many of our runners do. This is #MySoreSpot number 2 of our top 5.

  • See and hear Lori's patient describe what happens when Postural Restoration Institute® (PRI) techniques are applied to help her "feel the floor."

  • Read more about the mission of our PRIME program and why it is different. A good read for patients and referral sources explaining what we do and why.

  • Here is a video blog from Lori describing #WhyYouHurt if you have right piriformis (posterior hip) pain that may or may not have sciatic nerve implications when you run. This was one of the top 5 common sore spots as reported at the Lincoln Marathon Expo. ENjoy

  • Lori Thomsen describes the biomechanics behind the common human pattern we see that helps us determine #WhyYouHurt. Watch for upcoming blogs that will outline specifics how this pattern can cause specific areas of pain and describe the top 5 sore spots as reported by Lincoln Marathon runners at the 2016 expo.

  • #MySoreSpot

    Look for our staff at the Lincoln Marathon Expo, or follow us on social media (Facebook, Twitter and Instagram) this weekend as our staff will be there getting people to tell us about their sore spots. There will be fun surprises and opportunities for you to engage with us (potentially win a prize) and have a little fun before the big race on Sunday! Hope to see you there!

  • Caiti gives a great summary of what we are learning and doing here at the Hruska Clinic(TM) after taking a few days off last week for the Postural Restoration Institute®'s annual Interdisciplinary Symposium.

  • Caiti provides a brief explanation on assistive device functionality.

  • 持ってる 君は これまで されて 圧倒 "Have you ever been overwhelmed" Think of the first time you were ever exposed to Postural Restoration® whether you were a patient or a clinician you may have been overwhelmed by the visit, terminology, or even what you felt or saw. From a clinician's standpoint the language used is sometimes hard to follow. Now imagine what Yusuke felt like when he was trying to learn the Postural Restoration Institute® (PRI) language/concepts yet in another language (English). This goes to show you Postural Restoration® is becoming more of a universal language across the world and yes they have similar patients in Japan with the same patterns we have here in the United States. This blog discusses Yusuke Namba's observation time here at the Hruska Clinic(TM) (English Version).

  • Straight out of the Hruska Clinic(TM), Jason Masek's third article will be published in the Co-Kinetic (formerly known as SportEX) April 2016 issue, as well as online at https://co-kinetic.com/#_l_5w. Here is a preview!!

  • Yusuke Namba spent some time in the Hruska Clinic over the last several months and discusses his experience while at the clinic.

  • Jason demonstrates how activating a left ischiocondylar adductor and left abdominal wall eliminates right rib and intercostal wall pain. Check out his latest video blog.

  • Dave shows a unqiue way to improve balloon blowing technique for those people who struggle to find the power to get air into the balloon. This technique, that originated at the Hruska Clinic(TM), is taught as a core exercise through the Postural Restoration Institute® (www.posturalrestoration.com) and has been adapted and utilized to assist in treating anyone from the geriatric population to college athletics and professional sports teams.

  • A little blog from Torin discussing why we may be concerned about your neck if you need PRIME or multidisciplinary care. It also starts to discuss a little bit about the role of sensory integration and its potential influence on the success of a PRI® program.

  • Hear from our newest PT, Caiti Daubman, as she introduces the influence of oral-motor activities on breathing, and cervico-cranio-mandibular management.

  • Click here to access the newly updated 2016 shoe list and a video blog from Lori outlining the most recent changes and updates to the list.

  • See how treatment at the Hruska Clinic using Postural Restoration techniques is so unique. This article tells the story of some recent patients who presented with similar presentations and were treated with a different spin on visual input, as well as 2 other patients in our PRIME program who presented totally differently but were treated with a very similar approach. Everyone is unique but can be managed as long as you have a foundation to treat from.

  • A PRI perspective on the use of smartphones and its influence on your body systems. Includes some nice tips on how to safely navigate our ever more plugged in world.

  • Torin talks about the capital of Hungary, mnemonics, and what to do if your program is not working.

  • This video demonstrates the ability to sense the floor allowing an individual to move more fluidly. This individual's current footwear does not allow her to "sense" her entire foot on the floor, therefore her movement is impaired

  • Learn about what the Hruska Clinic PTs think about Multidisciplinary Integration.

  • Lori Thomsen from the Hruska Clinic in Lincoln, NE discusses a case study with an anterior open-bite.

  • Hruska Clinic's Jason Masek speaks on "Positional Influences, Breathing, and Performance: The Utilization of Postural Restoration for the Strength & Conditioning Specialist" at the 2015 NSCA Coaches Conference in Louisville, Kentucky.

  • The most up-to-date recommended shoe list provided by the Hruska Clinic. Click on the title to check it out!

  • Physical Therapy Student from Columbia University, Kasha Stevenson, discusses what she has seen at the Hruska Clinic

    Hi, my name is Kasha, I am from Vermont and am a physical therapy student at Columbia University doing a 9 week internship at the Hruska Clinic.

    “I’ve been everywhere and tried everything. Nothing took my pain away until I started coming to the Hruska Clinic.” This is the most frequent comment I hear from patients as they arrive from all over the United States (and sometimes abroad!) with different complaints and stories that usually started years ago.

    Hour appointments allow a full history to be taken of the life the patient has lived and questions are asked that sometimes may seem obscure. Yes, it is important to know that you played the saxophone for 12 years or that no matter what shoe you wear you always get a blister on the outside of the right big toe. All of these details allow the experienced physical therapists here to understand the positions that your body feels comfortable. These small details are critical.

    I am short of breath throughout the day or my legs want to keep going but I feel like I can’t get air in. This is something else I constantly hear at the Hruska Clinic. Breathing correctly is crucial. All sorts of pain and chronic problems stem from poor breathing. You may feel short of breath throughout the day, but most people do not know they struggle to breathe because the body naturally and efficiently compensates. Different postural positions and manual work can help to diagnose inadequate breathing and patients are amazed at how hard it is to breathe in some positions. And yes, there are a lot of balloons blown up here!

    Integration and engagement. This is something people talk about, and here at the Hruska clinic it is put into action with each case. Patients are engaged throughout their treatment and expected to take responsibility. In some instances their care is integrated with the dentist, podiatrist, or optometrist on staff. Why would you need to see a dentist or podiatrist or optometrist for shoulder pain? Neurologically sometimes other systems are playing a role and need to be addressed. For example, sometimes when a patient cannot close their mouth and feel all their teeth back and front, both left and right this can cause instability in the mouth and impingement or pain elsewhere because the patient’s body needs stability. Also, if a patient sees too clear or isn’t aware of their peripheral vision it can cause the eyes to be too focused and not allow the body to relax.

    I had not experienced this kind of integration between these professions before coming to the Hruska Clinic. During my 7 weeks I have seen a lot of cases where this integration between professionals allowed a patient to be pain free for the first time in years.

  • Trevor Rappa talks about The Effects of Breathing on the Autonomic Nervous System

    Every patient or clinician who is familiar with PRI knows how important breathing is when performing PRI exercises. The reason for this is the effects that breathing has on the Autonomic Nervous System (ANS). The ANS is what controls our heart rate, respiratory rate, perspiration, digestion, and the other functions of our body that we do not think about on a moment to moment basis. The ANS has two divisions, sympathetic and parasympathetic. The sympathetic division is what works when we are anxious, scared, angry or anything else that gives us a big rush of adrenaline, it is the “fight or flight” response. When you are in a sympathetic state your breathing becomes shallow and rapid while your posture becomes more upright, or extended, which means your muscles have increased tone. You are stuck in the inhalation phase of breathing. The parasympathetic division is what is working after you eat a big meal and get sleepy, hence why it is often referred to as the “rest and digest” response. When you are parasympathetic your breathing slows down and your muscles relax which allows you to achieve a position of flexion. You are in the exhalation phase of breathing. The ability to get between these two states is called neutrality. The tests a PRI practitioner performs lets us know if you are neutral. If you have increased sympathetic tone then your joints will be in a poor position and not be able to move certain ways, for example your hip may not be able to fully adduct. This test result shows us that you are not neutral. Essentially, with these tests we are evaluating the state of your ANS.

    The ANS is the reason why sometimes PRI practitioners ask questions that may seem unrelated to what you have come in for. You may come in because you have knee pain when you run but then get asked questions about if you get headaches regularly, have stomach pain, or wake up multiple times during the night. This is because studies have shown that people with chronic headaches 1 , stomach pain 2 , and sleep apnea 3 ,4 have increased sympathetic tone. The answers to these questions help us know if you have a problem regulating your ANS, or getting neutral. If you are stuck in a sympathetic state before you run, during your run, and after you run then you are putting extra stress on certain areas of your body, which in this example may be your knee. By helping you slow down your breathing, such as with a balloon in a 90/90 position5, we can help you get into a parasympathetic state. This will put your muscles and joints into a better position to function which often relieves the stress that may have been causing those areas to hurt. If this worked, then our tests would show that you are neutral which in the example before means that your leg would now be able to adduct. This is why we focus on breathing with every patient that we treat.
    -Trevor Rappa

    1. Jason J. Gass, and Alan G. Glaros. “Autonomic Dysregulation in Headache Patients” Appl Psychophysiol Biofeedback 2013 Dec;38(4):257-63. doi: 10.1007/s10484-013-9231-8.

    2. C. Botha, AD. Farmer, M. Nilsson, C. Brock, AD. Gavrila, AM. Drewes, CH. Knowles, Q. Aziz. “Preliminary report: modulation of parasympathetic nervous system tone influences oesophageal pain hypersensitivity.” Gut 014 May 28. pii: gutjnl-2013-306698. doi: 10.1136/gutjnl-2013-306698.

    3. Monaco, Annalisa, Ruggero Cattaneo, Luca Mesin, Edoardo Fiorucci, and Davide Pietropaoli. “Evaluation of Autonomic Nervous System in Sleep Apnea Patients Using Pupillometry under Occlusal Stress: A Pilot Study.” Cranio®(2014): 0886963413Z.000. Web.

    4. F. Abboud, and R. Kumar.“Obstructive sleep apnea and insight into mechanisms of sympathetic overactivity.” J Clin Invest 2014 Apr 1;124(4):1454-7.

    5. Boyle K, Olinick J, Lewis C. The Value of Blowing Up a Balloon. N Am J Sports Phys Ther. 2010;5(3):179–188.

  • Torin Berge Discusses how to keep on path with Postural Restoration

    Here at the Hruska Clinic we utilize a theory of treatment called Postural Restoration. This theory of treatment is taught to PTs, strength and conditioning specialists, athletic trainers, and others across the country through the Postural Restoration Institute. There are 3 basic courses, 3 advanced courses, a yearly interdisciplinary seminar, and at present 3 affiliate courses with more to come I am sure. There is a lot of information to learn to put the whole puzzle together. There are a few main points that we look at and then numerous intricate, interrelated components that influence each other to complete the whole puzzle. When you are first exposed to the science either as a clinician at a course or as a patient or athlete in the clinic there is no way to know or understand it all. It isn’t necessary to understand it all as long as you have a general picture of the main points. Once you understand the main points the rest of the puzzle continues to reinforce and connect the other points together to expose a beautiful, intricate, predictable, interrelated system. This is the beauty of Postural Restoration. The more you put the pieces together the more the whole system is understood in its entirety. The main concepts don’t change. What changes is how you see them in relation to the other concepts, which allows you to be effective in managing or treating the whole system. There is a lot of information in prior blogs on this site or on http://www.posturalrestoration.com about the basics of the theory. In general we hold a belief that the human body is inherently asymmetrical in its anatomy (mechanics), neurology (wiring), and physiology (function). This leads to inherent, predictable patterns that direct and are directed by movement, respiration, reflexes, and growth and development to name a few. This predictable pattern of asymmetry, when not managed, can become over dominant and lead to (bio)mechanical, neurological, and physiological states of imbalance. Our ultimate goal is to inhibit the over dominant patterns of mechanics, neurology and function to allow the entire system to achieve a state of rest (neutrality). This now becomes a starting point to re-establish balanced, efficient, alternating and reciprocal activity which should limit compensatory activity that is usually the culprit for inefficient movement patterns, pain and dysfunction. In order to get to that starting point you’ve got to understand the basics. What does the pattern look like from a mechanical, nuts and bolts standpoint? What causes the pattern, from function, physiology (respiration), and neurological influence? What influences the pattern in terms of behavioral, or activity influences? Where do I start?

    If you stop at the nuts and bolts components, in terms of getting the physical body into a state of neutrality or alignment, you really haven’t helped the whole system. If you understand the factors that influence the pattern but don’t understand the neurology (aka brain) behind it you will only influence part of the system and you will not succeed fully. While this is great talk and hopefully can spark some great discussion and questions, what does it look like in real life. This was my train of thought last week, after having some great discussions with visiting PT students, PT’s, coworkers and patients. It all came together, however, as I was working with a patient I have worked with for some time. I would like to outline generally the case and hopefully use it to show the beauty of the system, the power of interdisciplinary care, and ultimately to encourage both patients and clinicians that may be reading this.

    My patient initially came to the clinic for lower back pain that started 2 years previously while dead lifting. As an athlete this patient had lifted weights for years but this time it didn’t go so well. 2 years of traditional PT, chiropractic, core strengthening, massage therapy, and traditional treatment had gotten the patient no better. There were also complaints of neck tension, chronic knee tendonitis, headaches, and other minor chronic issues The patient initially presented to me with a predictable pattern that was identified with orthopedic, nuts and bolts, range of motion tests. These tests described and identified a mechanical pattern. But we also know that it described an autonomically modulated, neurological, respiratory, function-driven pattern. Nonmanual techniques (exercises) to reposition the pelvis and ribcage (nuts and bolts, orthopedic minded perspective) through inhibition of the neurologically driven pattern was initiated. They were successful immediately. Unfortunately, the patient was unable to maintain the new pattern once upright. Symptoms could be improved but not maintained. My first question was biomechanically what is driving this patient into a poor pattern once upright. We looked at footwear and eventually got this patient custom orthotics due to increased tibial varum and lack of appropriate subtalar joint flexibility to get his foot to the ground during stance phase of gait. This mechanical issue led to a neurological compensation in the gait pattern that prevented this patient from staying neutral with upright activity. Once in orthotics, the orthopedic tests at the hips were in a position of neutrality and back pain was better. Unfortunately neck tension increased. Neutrality was not achieved in the neck. Mechanically the influence of tooth contact placed his head (maxilla) and neck (mandible)in a position that matched the old neurologically driven pattern. Tongue depressors between the teeth immediately improved the neck mobility and a flat-plane mandibular appliance was recommended. This eliminated neck tension at work and at night. Non-manual techniques were progressed to improve alternating reciprocal activity in a bio-mechanically neutral position (held there by 2 sets of orthotics). Sounds great. Unfortunately, we continued to struggle with left hamstring tightness, left ischial seat soreness, and inability to increase activity levels because of this. Modifications of orthotics didn’t help. So what was missing? In orthotics we had achieved neutrality from a mechanical, ‘nuts and bolts’, orthopedic mind set. (without them the pattern returned immediately) While the orthotics did mechanically help with “alignment” and did give the patient better more appropriate (sensory/neurological) reference centers, and the non-manual techniques were in place to improve the strength, the patient still had a neurologically-driven system. In this case the patient perceived visual input from only one eye (the right) and did not not care or perceive the left visual world to appropriately shift or utilize space on hue by left side. All that was perceived by the brain through the visual/vestibular system was the right side. Essentially this patient was mechanically placed and held in a position of neutrality where the left hamstring should have been able to stabilize his left ischial seat, but neurologically was still constantly referenced to the right. By patching the right eye and walking up and down the hall we immediately neurologically opened up the left world and allowed the patient to reference left which immediately took the demand off the left hamstring and he had immediate full pain-free SLR and pain-free gait. The discord mechanically and neurologically seems to me at least to have created a functional tug of war at that left hamstring attachment, which was this patients last source of pain and typically the first place we hope to stabilize. The patient lacks one last orthotic, the one that will influence the neurological aspect of the pattern the most, and that is why he is now referred to PRI Vision.

    So what was the main factor in this case? Was it a weak left hamstring, was it a mechanical tibial varum and lack of subtalar joint mobility, was it a poor bite pattern/cranial-cervical reference, or is it the eye (of course we mean the way the brain is interpreting the signals sent
    to it by the eye)? The answer of course is yes on all counts. If just one issue was the main factor we would have been able to progress pain free at that point. In this case there was an underlying pattern influenced by both mechanical and neurological causes that all had to be
    addressed to fully have success. Of course we know that even our non-manual and orthotics are primarily neurological tools that will influence the biomechanics of the system. Treatment followed a systematic pathway using predictable patterns to identify factors influencing this person’s ability to properly inhibit strong patterns to perform activity in a reciprocal and alternating fashion without dysfunction, compensation and ultimately pain.

    So the takeaway I hope to give to patients and clinicians is this. Keep on the path. If you are a patient and step one and step two and step three didn’t seem to completely resolve things, keep on the path. There is a plan and a pathway to help. If you are an experienced clinician with PRI and struggling with a patient, keep on the path. Think biomechanics, but think about the brain and the neurology behind the pattern as often that is the tool that can have the most power. If you are new to PRI and either don’t get it, or see it as just an orthopedic, posture driven theory, or are still just getting the ‘nuts and bolts’ and understanding how the pattern is described in an orthopedic way with orthopedic tests, keep on the path. Get that solid understanding and keep learning to get to the good stuff which is the brain and neurology and how that will have more impact on an entire system and will help better describe the power and beauty that PRI has. I hope this has been helpful. Let me know if you have any questions or concerns and I hope to see you on the path.

  • Trevor Rappa from Columbia University at the Hruska Clinic

    My name is Trevor Rappa and I am a PT student from Columbia University in New York City. Before going to PT school I attended Amherst College where I was a member of the football team. Playing football gave me a love for strength and conditioning which I pursued during an internship at Mike Boyle Strength and Conditioning. I was first introduced to PRI by my close friend and classmate Greg Spatz. Since taking my first PRI course with Ron Hruska in October 2013 I knew that I needed to learn more. This brought me here to the Hruska Clinic where I am fortunate to be doing a ten week clinical rotation. During this time I hope to share some of my experiences, thoughts, and lessons learned through this blog.

    I hope you enjoy!
    -Trevor Rappa

  • Trevor Rappa talks about Neutrality

    Neutrality and Human Performance
    My mentor Lori Thomsen has emphasized neutrality during my first two weeks at the Hruska Clinic. This weekend I took PRI Integration for the Home with James Anderson and learned about Human Performance. I hope to share my understanding of how these two concepts are related.
    Tasks along a spectrum require the same foundational components. Rolling in bed and hitting a baseball require the ability to rotate your trunk. Standing up from a chair and dunking a basketball require force production from your hip extensors. All of these are on the same spectrum of human performance but at opposite ends. As James said during the course, an 18 year old and an 80 year old are both athletes, but one doesn’t move as fast as the other. Neutrality is the foundation that human performance should be built upon.

    Neutrality is variability, a concept I was introduced to by Bill Hartman and Eric Oetter. This variability is seen in movement and in autonomic states. Neutrality is the ability to move in three planes, alternate and reciprocate, and demonstrate symmetrical movement patterns although we as humans are not symmetrical! This puts muscles and joints in the best position to potentially express speed, strength, quickness, or any other physical attribute.

    Tri-planar performance is something all athletes should be able to do regardless of age. This is achieved by inhibiting our motor dominant left hemisphere which drives us into a right lateralized pattern (L AIC) to allow ourselves to become left lateralized (R AIC). Being neutral means that you are able to move back and forth between these lateralized patterns (perform gait) which indicates movement between the hemispheres of our brain. With excessive lateralization comes reduced variability.

    Autonomic variability is transitioning between sympathetic and parasympathetic states. It allows one to be “on”, or sympathetic, during times of stress such as during a game and “off”, or parasympathetic, when there are no stressors and rest/recovery is needed. Being “on” is necessary at times to respond to certain stimuli, such as reacting when you lose your balance so you don’t fall or performing a max effort lift. It is good to become sympathetic when necessary, the problem comes when you cannot turn it off. A period of rest and recovery is necessary to integrate a stimulus that requires a high recruitment of energy sources into the system. This will allow one to handle the stimulus even better the next time they encounter it.

    Neutrality is not a single point on a scale but it is a state that can change. After the course Zac Cupples, Conor Nordengren, and myself spoke with James on this idea of neutrality and human performance. To end this post I would like to share what the four of us came up with during our talk which I think ties this post together. “Achieving neutrality by minimizing lateralization and establishing autonomic variability.” This expands human performance.

  • David Drummer talks about flexibility

    Can a person be too flexible? I think most would argue the more flexible the better, but I have to disagree. I can’t tell you the number of patients I’ve worked with that I’ve told to stop stretching. And I always love the response I get of utter disbelief. Many will say something to the effect of “But I stretch everyday so I can place my palms on the floor”, yet they often have been fighting chronic pain for years with no idea why. After all, they’re active, otherwise healthy, and they stretch everyday.

    Have you ever been on a walking bridge with a lot of other people? If so, you’ve probably felt the bridge give or drop beneath your feet. That is by design. If the bridge doesn’t give with the varying frequencies of all those feet pounding on it, the bridge could collapse. Being too rigid could be devastating to the structure. On the other hand, there needs to be some rigidity or structure to the bridge, or again the bridge could collapse. Neither scenario is good.

    It’s the same with our bodies. Being too rigid, or lacking flexibility can lead to problems. Maybe you can’t reach down to put on your shoes and socks, or you can’t turn to see behind you when changing lanes in your car. But if you’re too flexible and you don’t have stability you may have back pain every time you lean over to pick something up or work in your garden. The list of problems that develop from too much or too little flexibility too long to cover in a short blog, but I hope you better understand why sometimes when you come to the Hruska Clinic you may be told to stop stretching.

    If you have any thoughts or questions regarding my thoughts on flexibility, please feel free to contact me personally.

    Dave

  • Hruska Clinic Clinical Integration Mentorship Program

    Often times we get requests from local, national, and international physical therapists, athletic trainers, and other healthcare professionals wanting to spend a day at the Hruska Clinic™. We have recently developed a program to allow these indviduals the opportunity to shadow the Physical Therapists from the Hruska Clinic™ during their day-to-day interactions with their patients as well as integrating with other healthcare professionals. Completing a clinical integration mentorship program can provide the Postural Restoration® practitioner the added confidence and experience in implementing Postural Restoration® concepts and techniques. Check out the Hruska Clinic Clinical Integration Mentorship Program!

  • Washington Mystics' Head Athletic Trainer Visits the Hruska Clinic

    You’re going to Nebraska again? What’s in Nebraska? These are the questions I was asked by my players, friends and family. Yes, I was visiting Lincoln, Nebraska for the third time in four months. After taking all three home study courses and five different live seminars from PRI, I was still missing something. I was not connecting the dots between what I had learned and what I needed to do, so I decided to spend a week at the Hruska Clinic to observe the treatment approach put into practice. The trip was exactly what I was looking for; it was amazing!

    Going to the Hruska Clinic every day and seeing Ron, Lori, Torin, Dave and Jason actually treating and evaluating patients was fascinating. Observing them, and experiencing the PRI clinic staff go out of their way to explain what they were doing and why they chose specific treatments and exercies, was exactly what I needed. I had my “Ah-Ha!” moment when all the training clicked, and I became comfortable and confident with what I had learned. I finally knew what I need to do in PRI evaluations and treatments. The trip was invaluable for clarifying my studies and moving me from simply knowing to actually understanding.

    My co-workers may say that I am drinking the PRI Kool-Aid, but after traveling the world and learning from the best osteopaths, chiro-practitioners and physical therapists, I am a firm believer that PRI should be the first technique used in treatment—similar to building a good foundation for a house. It is clear to me that without achieving neutrality, our subsequent treatments won’t be successful. I am so happy that I chose to take the final step of observing at the clinic.

    Navin Hettiarachchi

    Head Athletic Trainer
    Head Strength and Conditioning Coach
    Washington Mystics

  • You're Grounded!

    You’re Grounded!! (But hopefully in a good way…)

    “You’re Grounded!!” Luckily my kids are complete angels and I never have to say this at home… But at work I get to try and ground people all the time. Let me explain.
    Recently the Postural Restoration InstituteTM hosted their annual Interdisciplinary Integration Course. This year the topic for the symposium explored the influence of gas (air) and gravity on our ability to control our bodies with movement and at rest. The symposium also described some common challenges that we experience in the clinic with people who struggle to deal effectively with gas and gravity. Some labels given to people who are challenged with their ability to manage gas and gravity include orthostatic intolerance (OI), dysautonomia, POTS (postural orthostatic tachycardia syndrome), chronic fatigue, scoliosis, and dizziness. In the clinic what we find with people with these challenges is an inability to appropriately perceive where they are in space due to a limited ability to appreciate sensory, physical, visual, or vestibular cues. We call these sensory cues reference centers. Our brain utilizes sensory input from many different areas including your feet, joints, muscles/tendons, eyes, auditory and vestibular portions of our ears to know where we are at in space, where we are at compared to everything else, and what we need to do to maintain that position or move. The brain is constantly receiving, filtering, processing and responding to those cues literally thousands or millions of times a second (see quote at the end of the blog). This takes place automatically of course through a system called our autonomic nervous system (ANS). When that information is skewed, missing, or unable to be processed effectively, our ability to hold our bodies up against gravity, move or regulate our bodies becomes challenged and symptoms ensue. These symptoms are usually then related to functions of the autonomic nervous system including dizziness, poor management of heart rate or blood pressure, digestive troubles, poor sleep regulation etc. Many more issues arise when this system designed to regulate the majority of our body’s functions becomes stressed. We may talk more specifically about these at a later date; however, the purpose of this blog is not to describe physiologically what is going on but to try to start to clinically give some ideas of what to do about it.

    With this type of patient the main issue that needs to be addressed is giving these patients appropriate sensory reference centers or things to feel to allow their jacked up nervous system to relearn how to regulate itself. Any traditional activity, PRI based or not, that does not give these patients an appropriate, sensory, significant reference center is going to have limited success. There are a lot of things that we can think about to get good appropriate sensory input, but what I want to focus on now is feeling appropriate ground contact with your feet. We want our patients, especially those who are struggling with gravity to effectively and appropriately feel the floor underneath them. We want them to be grounded. As each foot hits the floor with walking or standing there should be input sent from your foot to the brain about where your body (center of gravity) is at in comparison to that foot, what direction, if any, the floor is tilting or moving, and many other sensory cues that the brain can use to feel secure, or insecure, about its position in space and how the body is moving. If those cues are absent, not perceived, or poor, the body loses a lot of information and security in its ability to maintain posture and move without jacking the autonomic nervous system up and going into a state of extension or fight/flight (AKA the bear in the room syndrome). If our patients do not feel a connection, or grounding, to the floor through each foot alternately they will not feel comfortable in their ability to walk, move, or hold themselves up against gravity, no matter what shoe, orthotic, lift score, breathing pattern, or pair of glasses they have on. A connection to the ground and floor limits the need for extension (back and neck) muscles to pull us up. Imagine a marionette puppet. You know the puppets with strings holding them up that you can use to make the puppet move, or walk (if you still don’t know google ‘N’sync no strings attached’). I tell my patients that they are a marionette puppet and if their feet are not connected to the ground when the walk the strings are pulling them up. The neck is usually the puppet master. Keeping them pulled up and away from the ground. If they can get connected back to the ground the puppet master’s strings (neck) can go on slack or relax.

    In the clinic I will often ask my patients to stand and tell me how heavy they feel. I will say “if you weighed 100 pounds (the math is easier and then I don’t have to guess weights) how heavy do you feel, or how much of that weight is on the ground through your feet? People will often tell me they feel much lighter than 100 pounds, or they feel 20 pounds on their feet but 80 pounds on their back or neck. For those people the floor starts at the low back or neck and the puppet master is pulling them up. They are floating away, probably dizzy or unstable, not neutral, and preparing to fight or run from the bear in the room. If I can get them to feel 100 pounds on their feet and ground them to the floor the puppet master will no longer need to pull them up, they will be more secure, probably neutral, and more relaxed. One tool that I will use to show people is to make a belt out of 2- 3# ankle weights and strap it to their waist with one weight on each ilium. As they stand and shift and walk they should be able to feel the weight transferred down to their feet. As one foot is picked up the weight on that ilium will pull down and ground them to the other foot. As they alternately move and walk their brain will become more grounded and the puppet master (aka the neck) can relax. I will often check them out and they will be neutral. Have them stand up, take the weights off, and they can often feel themselves getting lighter and floating away. Now not neutral.

    Now you could have them wear an ankle weight belt, and maybe that is the new up and coming fashion, but how are we going to get that carryover to the rest of their life. If we aren’t going to push their feet down into the floor we need to have the floor push up into their feet. This is what I want my patients to feel. Not just an awareness of the floor or an arch or a heel, but can they actually feel the floor under their foot come up as they shift their weight to that leg. With each step as you shift from side to side the floor (right or left) should come up into your foot as weight is loaded on to it. If not they are floating, not grounded and extending. If you can feel the floor as a stable base you can now shift, turn on a glute, and push yourself forward. Initially this needs to be a conscious thought, not with every step you take but with specific exercises. Let’s take a retro stair exercise that is done a lot for lots of reasons. We normally would cue our patients to step up with their left foot, shift their hip back and to the left to get their pant zipper over their toe, and weight to their heel while keeping their back rounded. This is absolutely correct to get into left AFIR and we can then push slowly and use glutes to step up. Not a bad deal, but were they grounded? I know we felt a heel but did the floor come up. I have started to really emphasize the step of this exercise where they shift back to their left side. I want my patients (whether they are grounded or not) to feel the step push up into their foot as the shift back to their left hip. The emphasis needs to be on the floor coming up, not the hip going back. If they don’t feel the floor come up I will have them shift the weight back on the right foot and try again. As soon as they feel the step pushing up into their foot as they shift back immediately they feel more grounded and connected. If done correctly they all say they feel more muscle activity in their quad, inner thigh and glute as they feel the floor push up. I will tell them to resist the floor coming up and try to feel as if they are pushing the step down as they bring the right foot up to the next step. If the thought is to step UP they will not stay grounded, if they are pushing the step DOWN they will stay grounded. Go try it. Feel the floor come up, push the floor away, feel the leg load up and work harder. I am getting more muscle awareness and work with this cuing than with any other cues I give. This is a cue you can give with any standing activity. A passive AFIR squat: feel the floor come up as you shift back. Step overs: Feel the floor come up as you load the leg, push the floor away as you step over, feel the floor come back up as you tap the foot down. Forward stairs (normal walking): feel the step come up into each foot as you go up the stairs, push the stairs down as you go up. Squats/lunges: Feel the floor come UP (not your body going down) as you squat or lunge and push the floor DOWN as you come up. The more that feeling of being grounded becomes natural (and desirable) the less the puppet master wins.

    Bye Bye Bye… (one last N’sync reference for those paying attention)

  • Caitlin Daubman discusses her fifth week at the Hruska Clinic

    Week 5: “Life is Short , smile while you still have teeth.”

    This week was filled with patients visiting the Hruska Clinic from all over the United States. They traveled from as far as Massachusetts, Virginia, and Louisiana to stay the week in Lincoln in hopes of finding a solution to their complex health history and primary limitations due to pain. These patients were referred to us by the PT’s or ATC’s in their area for a second opinion or assistance with progressing their current program. Jason Masek’s experience in assessing and treating patients with cranial asymmetries as well as temporal-mandibular dysfunction was helpful for all of these patients. Each of these patients had a different primary complaint (hip pain, shin pain, headache, foot pain); and each of the patients had been through many different treatment approaches (injections, chiropractic, orthodontia, acupuncture, pharmaceuticals, or instructions to simply rest). However, none of these patients found lasting resolution of the pain.

    Jason evaluated them and none of them were neutral. Repositioning exercises were completed and patients were still not neutral. Footwear was corrected and reevaluation showed the same L AIC or PEC patterns. Therefore, something else was holding them out of neutral and locking them into their pattern. Another interesting piece of information was that these patients either were presently in braces or had just finished orthodontia repositioning their bite. Jason discovered that the issues for these patients was stemming from their bite. These patients had limited or suboptimal occlusion between maxillary and mandibular teeth due to cranial torsions or an elevated palate. Jason took them out of their bite through the use of an oral splint, and reevaluation showed the patient finally achieved neutrality! It was amazing that simply removing the patient’s normal reference centers (their bite), the patient easily transitioned to neutral.

    Treatment options for these patients included using oral splints during exercises to achieve neutrality and work the excessively weak and underutilized musculature that had been neglected for so long while being in L AIC or PEC patterns. The progress at the pelvis would be limited by the permanence of their TMJ/cranial positioning. Communication between physical therapist and orthodontist began and allowed for integration of a new plan of care for the patient. Treatment options included braces being removed or wires snipped temporarily, oral splints designed, and ALF’s were applied for palatal expansion in patients with symptomatic cranial torsions.

    To some, this may seem like very intense or excessive measures to take for a future treatment plan. However, these patients have been through it all and the next step suggested to them by their healthcare professions have been more invasive or permanent treatments (nerve blocks, piriformis release, jaw surgery, teeth extraction, plantar fascia release). Conservative care is an investment, and one that pays off in the patient’s future to achieve a successful outcome utilizing and optimizing your body’s natural anatomy and function.

  • Caitlin Daubman discusses her fourth week at the Hruska Clinic

    Week 4: “Never put off till tomorrow what you can do today.”

    This well-known phrase can be dangerous as many people have internalized it as a way of life.

    Like many of you, I know all too well the guilty feeling that accompanies being idle. However, I will aim to highlight the effects on our body when we operate like this, and methods to change it. We all have numerous stressors that bear heavy loads on us day to day. In order to deal with these, we feel compelled to keep up with the race. We operate in over-drive. There is a familiar feeling of fatigue- waking up from restless nights where sleep is interrupted by one’s own snoring, or jolting awake from halted breath, jaws sore from clenching, with panting breath and heart racing. You may be one of the many whose body demands a cup of coffee to get you through the morning hours before the ‘afternoon yawns’ set in. All throughout the day, your heels don’t touch the ground and you likely aren’t aware if you are even breathing - if you are, you can’t feel it.If you cannot identify with these as a reflection of your life, then thankfully YOU are doing something right! YOU are the person that the majority of society would like to resemble. As a PRC or PRT, you have probably heard these complaints from your patients/clients.

    Last week I had the opportunity to sit in with Jason Masek and Ron Hruska as they saw some interesting patients. These patients were young females which Ron and Jason discovered to be orthostatic insufficient or dysautonomic. They presented with chief complaints of distal extremity pain but also mentioned headaches, dizziness, and fatigue. Their gait cycles were fast short strides lacking heel strike and trunk rotation. In essence these women felt and moved as if they were weightless. These women- like many other future patients out there- are operating in over-drive. Their ribs are elevated, they are over-inflated, and their ANS has adjusted to match this over-active system. Ron and Jason helped them find the ground using purposeful movements powering forward by pushing with the LE’s, and they taught them how to breathe. After the PRI exercise interventions to embrace gravity and use the diaphragm with chest expansion to breathe, the patients were neutral and reported feeling better overall and feeling grounded.

    The Interdisciplinary Integration PRI © conference last week taught me a lot about this common issue in a growing patient population, and the methods to treat it. Using PRI techniques, we can play an important role in the management of symptoms that accompany orthostatic insufficiency and dysautonomia through: embracing gravity, exhalation, chest expansion, and the strength of the legs to power us on the journey!

  • Caitlin Daubman discusses her third week at the Hruska Clinic

    Week 3: Versatility

    The knowledge I have gained from the PRI Myokinematic Restoration course has been integrated to a deeper level this week. I have seen the therapists at Hruska Clinic prescribe PRI exercises to patients that are progressing to a high level and have greater ability to function with neutrality. A patient training for a marathon is able to run 8-9 miles before proximal hamstring pain sets in and then soreness persists afterward. Upon examination and testing, the patient was neutral and had sufficient hamstring and adduction strength. In my reasoning, the patient was neutral, had “hole control”, and was strong in most of the important areas. What could be the issue resulting in her pain onset only after so many miles?

    The PT noticed that the area contributing to the patient’s problem was the glutes. We learn in Myokinematics about the important role of the external rotation fibers of the Right gluteus maximus and the extension fibers of the Left gluteus maximus, while also the Gluteus minimus and medius for stabilizing the left. The right glute max needs to be a stronger pusher to allow facilitate transitioning of the body over to the left stance during gait, in doing so, it acts to rotate the sacrum toward the left during right stance/push-off. The left glute max needs to act as hip extensor to propel the body forward rather than a heavy reliance on the left hamstring muscle group.

    For treatment, it was really interesting seeing the Retro Stair activity to work BOTH areas! The versatility and benefits of this exercise to the whole body make it one of my favorites: increase left AFIR, stretch left posterior capsule, facilitate combination of Left adduction with gluteal activation, inhibiting the back extensors and hip flexors; allow transitioning from left to/from right and strengthening the right to be a ‘pushing’ side.
    1. Left stair ascent: Shift into the left hip and focus on stability by lifting the right leg and holding the position before pushing up.
    a. Working Left Glute Max Extension fibers, Left Glute Med and Min
    2. Right stair ascent: Shift into the right hip and focus on strength by pushing into right AFER and left AFIR placing left foot on to the next step.
    a. Working Right Glute Max ER fibers

    Caitlin Hoag

  • Caitlin Daubman discusses her second week at the Hruska Clinic

    Week 2 :
    “If you don’t know it by now, you don’t know it.” - A phrase commonly delivered by those who are beyond the hurdles of graduate school, and also a phrase that I internalize so to promote my procrastination of studying. Rounding out my last year of PT school, the PT Boards are quickly approaching and I am knee deep in the most interesting clinical rotation here at Hruska Clinic. I have a genuine interest and motivation to learn PRI material and I am receiving many opportunities to do so every day. Simultaneously, I’m preparing and studying for the PT Boards from the knowledge base that has been built over three years. There are several points I noticed this week that are congruent between PRI and Board prep material, and some areas that diverge.

    Here are examples of each:
    1. Comparable: Pumps within the body that return blood back to the heart

    a. PRI: I observed Ron Hruska treating a patient with dysautonomia, specifically diagnosed with POTs. I learned along with the patient
    while he educated us on the areas of the body on which this patient needed to focus. Treatment methods for patients with dysautonomia and/or POTS are centered in:

    - Finding and embracing gravity
    - Strengthening the LE muscles to act as a pump for the body below the iliac crest
    - Utilizing the diaphragm as a pump above the iliac crest.

    b. Boards: I read these three points as they pertain to Venous circulation in the Cardiopulmonary section I studied that night. We know that these are the methods the body uses to return blood to the heart. However, I had been unaware of how to integrate this material into an examination and treatment plan for this patient population as Ron demonstrated.

    2. Contrasting: Hip mechanics and range of motion testing

    a. PRI: limited supine SLR unilaterally indicates an anteriorly tilted innominate. Hamstrings are elongated due to pelvis position pulling the attachment sites further apart; therefore it limits the available motion into hip flexion.

    b. Boards: limited supine SLR unilaterally indicates a posteriorly tilted innominate. Hamstrings are short, strong, and tight, pulling the attachment sites closer together and limiting the available motion into hip flexion.

    There are always opportunities for new learning, re-learning, or understanding concepts at a deeper level. What are some concepts/areas that you find particularly interesting and/or challenging between conventional PT and PRI?

    Caitlin Daubman

    DPT ’14, MHA ‘14

  • Hruska Clinic physical therapist Lori Thomsen discusses a recent article in April’s issue of Running Times, titled “It’s all in the Hips.”

  • Caitlin Daubman Discusses her first Week at the Hruska Clinic

    Week 1:

    I have completed my first of eight weeks as an intern at Hruska Clinic. This is my last internship before graduating with my DPT in May. It feels like I have come ‘full-circle’ as they say. After seven years, I am back in my home town learning from the very people that inspired me to pursue the profession of physical therapy. The only things I knew about PRI was what I experienced first-hand as a patient roughly 10 years ago. As a freshman in high school, I became determined to be a physical therapist so that I could treat and help others the way Ron and the professionals at Hruska Clinic helped me. I wanted to practice truly individualized treatment plans, instead of the traditional therapy practice which is dominated by symptom management and protocols.

    Day one at the clinic, Jason asked me what I knew about PRI. To say I knew ‘a little’ about PRI was an understatement. I understood the exercises I had been prescribed over the years and their purpose. However, to examine, evaluate, assess and plan a treatment from the perspective of the therapist was far beyond my understanding. My brain operates conventionally with the material that has been ingrained in my mind from three years of a rigorous PT curriculum. Presently, the Left AIC and PEC patterns are no longer foreign terminology to me as I am reading about them in Myokinematics and observing them in our patients daily. I understand the asymmetries and exercises that are given to the patients due to continued explanations from Jason and the other clinicians here. Right now, I am a sponge. My wheels are constantly spinning, critically thinking, mentally processing, and comparing what I knew to what I am seeing and learning here. I have a great deal more to learn and I am enjoying every opportunity to do so.

    It is an unbelievable experience. Working with all of the clinicians and their patients has allowed me to see a great variety. I will continue to grow in my understanding and hopefully become more competent with PRI throughout the course of this internship.

    Caitlin Daubman, SPT’14 MHA’14

  • Can you feel it - Right Glute Max… Part Three of Torin’s series is here!

    After my last blog I recently went back online and Googled “smunching” to see if we’ve made any difference in the world. And this is what I found. http://www.youtube.com/watch?v=pSdY91QgKvw
    Not quite what I had hoped for, but if she feels better I guess at least it’s a start. If I am not making any sense check out my last blog on smunching for a little clarity. I was even hoping that we might see some smunching at the Super Bowl but all that came out of that was “Bradying.” Check it out here. http://sports.yahoo.com/blogs/nfl-shutdown-corner/bradying-sweeping-nation-next-48-hours-204736897.html No abs working with that one. Oh well.

    So far in my last few blogs I have highlighted the importance of finding 3 specific muscles on the left side of your body (namely the left inner thigh, or adductor, the left gluteus medius, and the left abdominals). All of those muscles are important to help us move our pelvis and trunk into a position to allow us to shift our body weight to the left more efficiently during walking and other activities. We did not focus on those same muscles on the right side because they are already active and strong because we typically like to stand on our right legs and shift our weight to the right side more than to our left. Those muscles on the right side don’t need to get stronger. However, there is one muscle on the right side of our pelvis that can get weak and is important for us to feel and get stronger. That muscle is the focus of today’s blog, and it is the right gluteus maximus muscle.

    To review, the way our bodies are designed structurally (the way we are built), habitually (the way we tend to move), and neurologically (the way we are wired with one side more dominant) leads us to have a common movement pattern where we can more easily shift our center of gravity to the right side than to our left. When this pattern becomes too dominant or overactive it leads to a shift in the position or posture of our pelvis, spine and ribcage. As a result of that shift it leads to a myriad of muscle activity to compensate and keep us going straight ahead while in the asymmetrical position. Think of it as if the alignment of your car was pointed more toward the ditch than straight ahead. As the driver of that car you would have to work harder or compensate to drive straight ahead because your cars alignment wants it to go into the ditch. Our pelvis position tends to shift forward and to the right orienting our pelvis and lower spine to the right (at the ditch) which in turns requires us to compensate with certain muscles on each side of our body to position our hips and upper back (ribcage) back to the left. If this pattern is too overactive and too much undesirable muscle activity is occurring (or not occurring) injury may result. Our focus of treatment here at the Hruska Clinic is to teach our patients how to perform specific activities, utilizing specific muscles, to put and keep our pelvis, hip and thorax (including rib cage, scapula and shoulder) in a more symmetrical (neutral) position, (pointed straight ahead), to allow movement and activity to occur more efficiently and with less restriction. So far we have highlighted three muscles on the left side of your body to pull the left pelvis, hip and lower spine into a more neutral position. Today we look at the right side.

    The gluteus maximus is a muscle that’s job is to extend (push back) your thigh bone and outwardly rotate it. In our normal pattern of asymmetry the right pelvis bone, or innominate, is in a position where the hip is in a position of adduction, internal rotation and extension. This places the fibers of the right gluteus maximus in an improper position (long and weak) to function as an external rotator of the thigh bone in the hip socket (rotate right thigh bone to the right), and more importantly to rotate the pelvis to the left when the thigh bone is stable during push off with walking. This means that during upright activity such as walking we have a much more difficult time pushing our body to the left to achieve a full hip shift to the left and leads to continued function in our asymmetrical pattern. So it is important for us to be able to utilize the right gluteus maximus, with the help of the left inner thigh, left gluteus medius and left abdominal, to fully push and shift to the left with dynamic functional activity. So can you feel it?

    Initially if you cannot position yourself with your left hip back and your right hip forward with your pelvis and spine pointing left it will be difficult to isolate or feel the right glute max work during your exercises. Therefore all the activities that we have discussed in the past to reposition your pelvis need to be addressed and maintained during right glute max exercises to feel it work correctly.

    Here are some more specific hints. If your pelvis has tilted forward, not backward, and your back is tight or overactive this will limit your ability to feel the glute, especially in an upright position. So think about tucking your bottom or emphasizing a posterior pelvic tilt, to better engage the glute. If the right inner thigh is too overactive and the left inner thigh is too underactive you will not feel the right glute max as well as you could, so make sure you fully shift your pelvis to the left and turn on your left inner thigh before you try to engage your right glute max. This will often help. Another activity in standing that can help is really focusing on pushing your right arch and big toe into the ground or shoe and not letting your right foot roll to the outside. If your foot rolls out onto the outer part of your foot, this will allow your whole leg and therefore pelvis to rotate outward putting you back into the normal asymmetrical pattern pointing you toward the ditch. This will limit the ability for your right glute to help push your pelvis to the left. Sometimes we may even put a small wedge in the outer heel on the right shoe and a little arch pad on the right side to give you something to feel to push your arch into to shut off your right inner thigh, turn on your right glute and shift your weight more easily to the left with gait. Hopefully these hints help you feel your right glute max more effectively with your exercises. If not do not hesitate to contact your therapist and ask them for some more specific hints. For more good information also check out Lori Thompsen’s latest video blog on getting your right hip and leg in the proper position.
    Is your right leg and pelvis in the correct position when you run?

  • We would also like to extend a sincere thank you to Asics for bringing back the Asics Foundation!!

  • Ethan Grossman from Peak Performance NYC spends some time at the Hruska Clinic

    Before visiting the clinic, I had previously been to 4 PRI courses and used the concepts extensively with my clients. I knew from my previous internship experiences that there is no better way to learn than to directly observe the best in action. I decided to spend two full days observing at the Hruska Clinic, and the investment paid off. Any questions I had at the time were cleared up, and I got a chance to see the way the PRI principles were truly meant to be carried out. The family of PTs and assistants at the Hruska clinic were incredibly helpful and welcoming. They even had a full schedule laid out for me based on my specific interests. I’m looking forward to making the trip to Nebraska again soon!

    Ethan Grossman
    Peak Performance NYC
    585-813-4040

  • Jason Masek provides great articles supporting Postural Restoration® Acetabular Femoral Movement

    I am currently putting together a manuscript on femoroacetabular impingement and recently came across these most recent published articles discussing how the orientation of the pelvis influences the acetabulum. Both of these articles provide the Postural Restoration® educated clinician with a valuable reference describing the relationship between pelvic tilt, acetabular orientation and its effect on femoral head coverage. I would encourage all individuals familiar with Postural Restoration® to take a very close look at these phenomenal written articles! I have provided excerpts of each article to entice those of you that are interested in reading the full article.

    The Cibulka article provides evidence to support Acetabular Femoral Internal Rotation (AFIR) and Acetabular Femoral External Rotation (AFER) concepts as it relates to Postural Restoration®. This article suggests that as one innominate bone moves backward the other moves forward. More specifically, a backward rotation of the left innominate would produce more acetabular femoral coverage of the left femoral head and a forward rotation of the right innominate would produce less femoral head coverage. Therefore, when the left innominate moves backwards it would place the femoral head in a relative internally orientated position (Acetabulum moving on a femur i.e. L AFIR) and a right innominate moving forward placing the right femoral head in a relative externally orientated position (Acetabulum moving on a femur i.e. R AFER).

    The influence of pelvic tilt on acetabular orientation and cover: a three-dimensional computerised tomography analysis.

    Dandachli W, Ul Islam S, Richards R, et al.

    Hip International. 2013 Jan-Feb; 23(1) :87-92.

    “Pelvic tilt in the sagittal plane influences apparent acetabular inclination, version and cover of the femoral head in the acetabulum.”

    “As the pelvis tilts forward, so the relative amounts of cover of the femoral head by the acetabulum change.”

    “Recognizing a pelvis that is significantly titled and not aligned in the anterior pelvic plane is important, and we have attempted to show how this would influence various parameters in terms of the relationship between the acetabulum and the femoral head.”

    Sacroiliac joint dysfunction as a reason for the development of acetabular retroversion: a new theory

    Cibulka MT

    Physiotherapy Theory Practice. 2013 Dec; 1-5

    “Changes in acetabular orientation can occur with alterations in pelvic tilt (anterior/posterior), and pelvic rotation (left/right).”

    “A unique feature that develops in patients with sacroiliac joint dysfunction (SIJD) is asymmetry between the left and right innominate bones that can alter pelvic tilt and rotation.”

    “an outward or backward rotation of the innominate bone would likely produce a more posterior and lateral orientation of the acetabulum; while an inward rotation of forward rotation of the innominate bone would likely produce an anterior and medial orientation of the acetabula.”

    “Rotation of the pelvis to the left mimics posterior or backward rotation of the left innominate bone and a relative anterior or forward rotation of the right innominate bone. Rotation of the pelvis to the left would also orient the left acetabulum in a more posterior direction (Levangie and Norkin, 2005) or retroverted direction.”

  • Lori Thomsen to host 2014 Running Clinic on Saturday March 1 at the Hruska Clinic. Deadline to register isTuesday February 25th. Please download brochure to register!

  • This article describes the various relationships that dental structures have in relation to whole body mechanics. Take a look at this article!!!

  • Lori Thomsen to Host Running Clinic Saturday January 25th at the Hruska Clinic

    Just a Reminder!

    ! Lori Thomsen to Host Running Clinic Saturday January 25th at the Hruska Clinic Deadline to REGISTER Wednesday January 22, 2014.

  • Lori Thomsen to host 2014 Running Clinic on Saturday January 25th at the Hruska Clinic. Deadline to register is Wednesday January 22nd. Please download brochure to register!

  • Sports Physiotherapist from England visits Nebraska and the Hruska Clinic

    Martin Higgins graduated in 2000 from Leeds metropolitan university. Martin works in private practice for Pro Sport Physiotherapy and has a specialist interest in low back pain and pelvic instability. He has worked in professional rugby for the last 14 years and currently is the Head of Physiotherapy at Leeds Rugby. Since 2011 he has also been the lead physiotherapist for Duffy Golf Fitness - a leading golf performance company working with European Tour golfers.

    Martin has been studying PRI via online study and wanted to visit the clinic to see PRI in practice first hand.
    ” My current clinical role involves working in professional rugby and golf. I am very fortunate to work alongside Kevin Duffy at Duffy Golf Fitness. He is one of the most innovative strength and conditioners working on the European Tour. In my private practice a high percentage of my case load is treating patients with chronic low back pain.

    At the PRI clinic Martin spent time with Jason Masek and also spent a morning with Ron and Heidi at the PRI vision clinic.

    ” It was an absolute privilege to spend time in one of the leading physiotherapy clinics in the world. The work that Ron and his team are doing is outstanding and it was a fantastic learning experience for me. It was great to work with Jason Masek, he does a great job of keeping a very complex science as simple as he can for his patients. One of the biggest things that I will take back to England with me after watching Jason in clinical practice is to try and keep things as simple as you can. Go for the basics of left AFIR, right apical expansion, gait and try to integrate PRI into standing activities as soon as possible.

    During the week, there was such a varied caseload and Jason treated patients of all ages.
    It was great to see the science of PRI in practice and with different patients at different stages of their rehabilitation.

    “When I graduated in 2000 I would never have thought that my career would take me to the American midwest! I had an amazing week with everyone at the clinic. I am not sure that the people of Lincoln know just what amazing therapists they have on their doorstep. For me, PRI has the most innovative and forward thinking physiotherapists in the United States if not the world. I am really looking forward to putting some of the clinical gems I learned during my time in Lincoln into my practice”

    Many Thanks again to Jason, Ron, Dave and all the team for making my week so memorable and I hope to be across again soon for more learning!

  • Walking in Circles!!

    Walking in circles?
    If you’ve been a patient at the Hruska Clinic you certainly have walked up and down our halls as your therapist watches you move and critiques your gait. How a person walks and moves tells us, as therapists, a lot about their postural and movement patterns and therefore their flexibility. How well someone shifts their weight from side to side, or swings an arm, or feels the floor with one foot compared to the other does tell us a lot about the patient. With our ultimate goal of getting and keeping our patients ‘functionally neutral’ walking or gait is an activity that we can use to judge and help achieve that goal. Symmetrical neutral gait shows balanced shifting or centering during each stance phase of gait, even stride length, even trunk rotation and arm swing etc. Our normal asymmetrical, right dominant pattern shows up in the way we walk, often with limited shifting or centering to the left, limited arm swing (particularly the right) and limited or asymmetrical trunk rotation. Humans prefer to shift and push off with the right leg and reach forward with the right arm and rotate the upper trunk to the left. This pattern is reinforced in activities such as running track that is always designed counterclockwise, which allows better shifting to the right and upper trunk rotation to the left. We would think then that walking clockwise would encourage left shifting and right trunk rotation and hopefully that is the case. But if our goal is to be truly reciprocal and balanced we need both.
    Let’s break down clockwise walking and counter clockwise walking to see what happens with our bodies during those activities. Straight forward walking is a truly alternating (right/left/right/left) and reciprocal (forward/backward) activity. The 2 phases of gait can be broken down into left pelvic rotation with right trunk rotation (think end of stance phase of gait with left foot on the ground and right foot and left hand moving forward) and right pelvic rotation with left trunk rotation (think end of right stance phase with right foot on ground with left foot and right arm coming forward.
    With the normal human pattern the second position is much easier to attain and find. Now imagine walking counter-clockwise around a circle. It is easy to see how that pattern could be utilized easier by taking s longer swing forward with your right arm and left leg as you turn to the left. Conversely if you imagine walking clockwise you can see how it may be more difficult to lead with the left arm and right leg to make that turn. Now I’ve sort of tricked you into thinking that way by showing you the pictures above and talking through the patterns. The thing is you still need to go through both phases of gait as you go around the circle either direction. As you turn counter-clockwise yes you will reach further with the right arm (easier left trunk rotation) but with the next step if you focus on taking a longer step with the right leg you will achieve more left pelvic rotation during the left stance phase of gait. And again with clockwise walking it is harder to reach forward with the left arm to achieve right trunk rotation, but with the next step you can step further forward with the left leg and more easily achieve right pelvic rotation. So truly which is easier or better for you? The answer is both…depending on the emphasis you place with each step. If you walk counter clockwise and emphasize a right arm reach and let the right leg take a shorter step it will be easier to the human pattern and not as beneficial. Also if you walk clockwise and just emphasize talking a longer step with the right leg to achieve right AFIR and don’t emphasize the trunk rotation it will be easier and not as beneficial.

    So here is my general recommendation. Walking counter-clockwise should be done with emphasis placed on right leg swing to increase left pelvic rotation during late left stance of gait and I can see being a very beneficial activity for anyone who has need for improved left pelvic rotation such as a hip impingement patient etc. Clockwise walking should be done with an emphasis on leading with the left arm to encourage improved right trunk rotation at early right stance, and would be beneficial for someone with right trunk (rib) rotation limitations such as someone with cervical pain/tension, thoracic outlet etc.
    In my next blog we will discuss an activity that can focus on both of these activities to really become alternating and reciprocal in our gait patterns.

    To view future blogs on this topic, visit http://www.hruskaclinic.com

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  • Happy Running!

  • Torin Berge discusses Sensory Awareness of Rib and Thoracic Rotation

    Sensory Awareness of Rib and Thoracic Rotation

    If you have read or explored our blogs you know that we have a strong belief that our bodies have a specific pattern that is fairly typical and predictable and actually desirable for many activities. When this pattern becomes too strong or ingrained problems develop. One of the main, if not the main, reason for this asymmetrical postural pattern is due to the inherent asymmetrical, structural, physiological and neurological make-up of our respiratory system. Just the act of breathing with this system that has a right and left diaphragm that are different sizes and positions, to get air into a chest wall that has different structures in either side leads us to assume this normal asymmetrical postural pattern. This pattern, termed a Left AIC/ Right BC pattern by the Postural Restoration Institute®, predisposes our bodies to a pattern of pelvic and spinal orientation to the right and upper trunk (thoracic) rotation to the left (think right arm reaching forward).

    Today I want to discuss this patterns effect on rib and thoracic rotation. This left upper trunk rotation through the thoracic spine places the left ribs in a state of external rotation and the right ribs in a state of internal rotation. The left rib cage is in a state of hyperinflation or inhalation and the right rib cage is in a state of exhalation and shows a limitation in its ability to expand apically. There are many ways that we can compensate for this natural pattern but in general this is what we see. One of the main treatment goals for all patients with a postural restoration program is to promote right upper trunk/thoracic rotation with right rib external rotation/expansion and left rib internal rotation once a neutral starting point or pelvis is attained so that proper reciprocal ventilation can occur. Most patients do well with integrated non-manual or manual techniques to obtain this goal. In my experience, some patients, especially those with very strong patterns that may be driven by or dominated by the visual/vestibular system and may be undergoing treatment through the PRI vision program, have a more difficult time understanding and feeling this necessary rib and trunk rotation. Therefore, I would like to further break this down for clinician understanding, patient awareness, sensory feedback, and in the end improved overall outcomes with patients who may be having a difficult time integrating trunk rotation into their programs or carrying it over into their daily lives.

    As described above, the normal pattern in the rib cage/thoracic spine that we are trying to inhibit includes a pattern of left thoracic rotation with right rib internal rotation/exhalation and left rib external rotation/inhalation. As we break this down further we will look at what we need to do on each side by itself and then provide some exercise examples and examples for activities to do throughout the day.

    In order to effectively promote right upper trunk/thoracic rotation, the LEFT ribs need to go into a state of internal rotation or go DOWN and IN. This should happen during the EXHALATION phase of breathing with the left arm reaching forward or PUSHING. This is a sagittal and frontal plane movement that should also include some activity of the left abdominals and left hamstrings if possible to provide a stable base on which to turn. Patients with exhalation dysfunction need to learn that the left side needs more activity as the exhalation side with left arm reaching or pushing to get the left ribs to go down and in.

    Right upper trunk/thoracic rotation also must to be accompanied by RIGHT rib external rotation or expansion. The right ribs must go UP and OUT during the INHALATION phase of respiration. The right hand can be used on the lateral ribcage or thorax for sensory awareness of right rib movement up and out on inhalation. This can also be accompanied by a right sided PULLING activity. This is more of a transverse (and frontal) plane movement and may need to be accompanied by left adductor activation for pelvic stability. So patients with more of an inhalation dysfunction need to learn and feel the right side as the inhalation side with ribs going up and out (with sensory assistance form the right hand as needed).

    Depending on the patient, focus should initially be on one phase or the other during respiration with a pause between. Gradually both phases of respiration could be integrated. There are specific non-manual techniques, developed from the experience of working with patients in the PRI Vision clinic, designed to obtain sensory awareness of rib and thoracic rotation in different positions progressing from sitting to standing to supine to side-lying. The key initially may not be how much range of motion is achieved for a left ZOA or right apical expansion but can the patient even feel and recognize that the ribs are moving. If there is no awareness of motion, how can we assume that the patients are carrying over the left ZOA or right apical expansion activities with their home program. For example in a sitting position initially you may start by reaching with the left arm forward during an exhalation and feeling the left ribs go down and in with a sagittal and frontal plane focus. Exhale and reach, feel it, relax, and then inhale gently. Repeat. Don’t think about the right side, just feel the left side and think exhalation. To emphasize the right side you would initially just focus on feeling the right ribs go up and back (use the right hand on the lower rib cage to feel it) during an inhalation with transverse plane motion. Inhale and feel it, relax, then exhale gently. Don’t think about the exhale or the left side; just think about the right side and inhalation. Eventually you could go do a repetition feeling both inhalation and exhalation starting on either one or the other depending on the needs of the patient. i.e. Exhale and reach with the left, feel the left ribs go down and in, Pause, inhale and feel the right ribs go up and back, then relax back to the starting position. Ultimately the sensory awareness and feedback gained with these activities proper rib and thoracic rotation will start to be integrated with daily activities and other non-manual exercise progression. See the specific non-manual techniques for details.

    Throughout the day activities that incorporate the different motions can be done. For example any time we perform an activity that requires pushing (i.e. pushing a door open or pushing a shopping cart) this should have a focus with the left arm and be done with an exhalation focus. So as we push a shopping cart through the grocery store frequently intentionally push with the left hand during an exhalation and feel the left ribs go down and in. Conversely any time a pulling activity happens (i.e. pulling a door open, starting the lawn mower, etc.) this should be done with the right arm with a focus on inhalation. So every time you open a door do it with the right hand as you inhale. Other activities done throughout the day that can incorporate these theories include rolling in bed, sit to stand transfers, and any activity in which you could emphasize right thoracic rotation. Gradually these daily activities will help the pattern become more easily felt, accepted, and automatic. I hope this helps you as either a patient or clinician get a better appreciation and feel for proper rib movement with thoracic rotation during each phase of respiration.

    Tagged with: Rib rotation, thoracic rotation, inhalation, exhalation, respiration, PRI Vision, sensory awareness, reciprocal ventilation

  • Joe Cicinelli provides a summary of his time at the Hruska Clinic

    My time at the Hruska Clinic has afforded me the opportunity to view a collaboration of healthcare professionals who—through great effort—have decided to raise the bar in healthcare. On a daily basis, new boundaries of human physiological potential were realized. Our inability to influence physiology may not be a limitation in physiology, but a limitation in our understanding. As Albert Einstein stated, “Complexity is that which we do not understand.”

    As a DPT student, I am faced with a strong culture of ideas of our interpretations of human physiology in the year 2013. If these ideas become strong enough, they can be recognized as fact. This perspective becomes our limitation in every aspect of life as we consciously and unconsciously accept the majority. Change becomes more of a burden than an exhilaration.

    For me, PRI has cultivated a future of accepting no limitations in patient care strengthened by the conduit of integration. This philosophy has the potential to take hold and permeate an entire culture. It gives the 12 year old scientist permission to dream. It lends a helping hand to the 72-year-old woman that refuses to chalk up her pain as “old age.” With the uncertainty in healthcare and the economy, PRI is a refreshing taste of a new reality.

    I believe PRI has provided students and practitioners a platform to launch a new paradigm of understanding in physiology and interdisciplinary integration. It supplies the opportunity to bridge a full spectrum of scientific research fields. If you are another student, practitioner, or any other seemingly unrelated professional out there that routinely asks “why,” understand that you are not alone. The future is coming and it can’t come soon enough.

    I would like to thank all of the patients and everyone at the Hruska Clinic for creating a life changing learning experience for me.
    “PRI is just the tip of the iceberg, but it is the iceberg.” – Lori Thomsen

  • Joe Cicinelli provides his interpretation of the PRI squat and it’s relevance to strength training.

    Implementing the PRI Squat in Strength Training
    When the PRI squat and barbell back squat are understood and integrated, this squat duo can be a powerful tool to regulate the autonomic nervous system for improved governance of adaptation. Both squats adaptive intentions are equally important in developing a healthy and resilient body.
    The PRI squat is a biomechanical position to consequently yield an autonomic response. Global extensor tone is inhibited as the pelvic floor sinks underneath a posterior tilted pelvis to effectively achieve a zone of apposition. This squat position places the diaphragm at postural ease as respiratory expansion is carried out in the posterior mediastinum. In humans, this squat position most likely extends as far back as the very beginning of transition into bipeds and possibly earlier. The PRI squat is the fundamental human position of defecation and rest.

    The back squat has been around since the birth of the barbell. It is the foundation of most strength training programs and possesses great ability to build maximum strength and, when programmed appropriately, any other desired change in energy metabolism. During the descent of a back squat, the pelvic floor remains in neutral relation to the lumbar spine as the weight is distributed through both calcaneal bones and across both arches. The spine is effectively locked within a neutral zone (neither flexion nor extension) to preserve the position of the central tendon of the diaphragm and optimal stabilization of proximal musculature. Maximal squat depth is realized when further descent creates accessory spine movement compromising force transfer through the kinetic chain. When loaded, this marked loss of “super-stiffness” has the potential for increased injury risk. Compromising a neutral zone can increase the stress applied to the ANS telling the brain to increase fatigue, thus reducing performance.

    When applying the PRI squat and back squat to the same exercise program, intentions of adaptation must be made clear to the athlete/patient. The PRI squat plays the role of the parasympathetic “off switch” and becomes a post-exercise appraisal of barbell technique. The back squat plays the role of the sympathetic “on switch” and serves the purpose of creating a hormone response and training the rate and capacity of energy production within the desired alactic, lactic, and aerobic systems. A primary goal of the back squat is force production! Even back squatting in a neutral zone can drive an athlete further away from neutrality because of the sympathetic state of the ANS. The big question becomes, “Can the athlete shut this sympathetic extensor tone off?”
    If an athlete presents with a 5/5 PRI squat and subsequently loses this ability after a set of back squatting, barbell technique may have to be addressed. If this same athlete continues to have difficulty with a full PRI squat, the athlete’s “off switch” is compromised. There is a depression in vagal tone potentially leading to an increased resting heart rate and blood pressure, along with suppression of anabolic hormones and the immune system. Continuing to back squat them may add more fuel to the sympathetic fire. Not being able to PRI squat can reduce the athlete’s adaptive reserves. Strength is signaled under the sympathetic umbrella and built under the parasympathetic. Post-training PRI squats can prime the PNS to jump start the powerful recovery capacity of the aerobic system.
    When applying these two squat techniques in exercise prescription, care must be taken to assess the individual’s baseline fitness level. Perception and exertion are unique to each person’s ANS. A PRI squat could impart a strong sympathetic stimulus to a de-conditioned athlete or serve as a prerequisite to a pistol squat. To a neutral athlete that back squats 500lbs, a PRI squat is rest. In athletics and the general population, the importance of developing force production and the capacity and rate of energy production are desirable adaptations to cope with the stressors of life. If a neutral person that can squat 300lbs moves a 30lb end table, the amount of stress on the physiological system is low. If a neutral person with limited strength development moves this same end table, this may be a relatively high stressor. The larger the physiological buffer zone, the further the person’s ANS is from sympathetic overdrive and loss of neutrality. If neutrality is a position of rest, it can be further maintained through greater amounts of stress because of the trained elevation in stress threshold.
    It would be irresponsible to allow athletes to step on the field or court against an opponent that has substantial advantage in the development of capacity and rate of energy and force production. Just as it would be irresponsible for these same athletes to walk off the field or court without being given the opportunity of neutrality. Both the back squat and PRI squat serve as powerful autonomic regulators for the same purpose of health and resiliency. Athletes/patients need guidance from educated coaches and health practitioners to pursue peak performance and the highest quality of life.

  • Lets get “Hip”

    Dave Drummer Gives A Basic Anatomy Lesson To Explain The Integrated Nature Of Your Body

    That is really hip! That saying may be a little out of the times (it dates back to when I had a full head of hair), but maybe it’s time for a comeback. If you’re familiar with our clinic, you likely know that we concern ourselves a lot with the pelvis (not to mention hamstrings, rib cages, breathing, feet…). As I tell a lot of my patients, your pelvis in many ways is your foundation. If you have a problem with your foundation, your whole body may be affected.

    For those of you who may not be familiar with our clinic and the way we practice let me explain. We will need to start with a basic anatomy lesson. The bony pelvis is made up of three basic parts: the left half of the pelvis (called the left ilium), the right half of the pelvis (the right ilium), and in between them is what is called the sacrum (at the end of which is the tailbone). The joint or connecting point, of either ilium with the sacrum is called a sacro-iliac joint (you have a left one and a right one). Your hip sockets are part of the ilium bones, and is where the large, upper leg bone (called the femur) attaches to the pelvis. If you were to look at the back of your pelvis, you would see a notch where a very large nerve called the sciatic nerve leaves the pelvis and travels down the back of your leg. Your spine or the column of bones of your back, are attached to the sacrum, and your head rests upon your spine. I think it is important to know that each of your rib bones attach to a specific region of the spinal column called the thoracic vertebrae and your shoulder blades rest on your rib cage. Finally (sort of), your arms attach to a portion of your shoulder blades that becomes the shoulder socket.

    Now, imagine that your pelvis is tilted, rotated, or generally out of a “normal” healthy position. A lot of pain issues can develop, including (but certainly not limited to), plantar fasciitis or other some foot pain, knee pain, hip pain, sacro-iliac joint pain, sciatica, or back pain. Even if you have shoulder, rib, neck or even jaw pain, it is possible that there are issues with your foundation (i.e. your pelvis) that will need to be addressed.

    When you come to the Hruska Clinic, we will perform a series of objective tests that will help us decide if there are postural issues related to your pain. We will then explain why you have your pain and what we can do to resolve the problem so you can feel good and resume the activities that you love. Who knows, when you’re done, you may find yourself saying, “Wow, the therapists at the Hruska Clinic are really hip”. Please, just don’t forget that we also love breathing, rib cages, feet…