The Hruska Clinic Integrator

What to do when it doesnt stick.

Physical Therapy and mnemonics
What to do when it doesn’t stick.
Have you ever tried to learn something, anything really, and you just could never seem to remember it. One example that I can think of in my background was having to learn the capitals of the countries in Europe when I was in junior high or high school geography. BORING. I had never (and still haven’t) been to any of these countries, had no reason to learn them-other than to regurgitate them for a test. There was little incentive to learn them. There was one capital that I could never remember, no matter how many times I was quizzed. Hungary. What is the capital of Hungary? Don’t go googling it if you don’t know it, I’ll let you know later. I will also explain why in the world I am even bringing this up.
In general, our goal with our patients who have overactive patterns of movement that create dysfunction and pain is to teach them how to use a new pattern of movement to decrease the stress created by the first pattern. I know that was a long sentence, but let’s make sure it makes sense. If someone has a strong pattern of right dominance where they are able to stand, shift and go to the right much better than the left, the muscles that either pull them to the right or push them to the right will be overactive compared to the muscles that push or pull them to the left. Therefore if I want to decrease the strain of a muscle that pulls them to the right I would try to encourage improved use of the muscles that pull them to the left and teach a pattern of left dominance or stance to accomplish that. One of the important concepts that PRI trained practitioners understands is that it’s not just about strengthening the muscle that would pull you to the left that needs to happen. The reason that that muscle is not able to work is not just about weakness. As the strong pattern develops, that muscle is now placed in a position where the orientation of the muscle fibers and the length tension of the muscle itself renders it inefficient to do its job. It functions poorly because it literally can’t do its job the way it’s being asked to do it. This concept is the first reason PRI trained practitioners learn to explain why a muscle just won’t strengthen or can’t be felt the way it should. Once the muscle is placed in the correct position it now at least has the ability to contract and work the way it should. One of the main muscles we see this in a lot is the left gluteus medius (however there a lots of muscles we could talk about). When someone is asked to either internally rotate their left femur in the socket (FAIR for you PRI folks) or stand and balance on their left leg (AFIR) the left gluteus medius should be one of the muscles working. However, if something different is felt (think TFL for FAIR and excessive quad or low back or calf for stance/AFIR) more repetitions of that activity won’t help things, it will only reinforce the bad pattern. In a right dominant pattern, which is typical as described above, the orientation and position of the pelvis and femur in relation to the pelvis places the left glute med in a position where it is ineffective to do those jobs so someone else has to pick up the slack (thank you very much TFL and low back). By repositioning the pelvis and femur (with the help of other left dominant pattern muscles) the gluteus medius is now in a position where it can engage and help and can now be trained and strengthened and viola things get better. This is what makes PRI concepts so helpful to rehab and performance specialists. We can identify and describe the pattern which explains why a particular muscle is not working and effect immediate change and help through position and inhibition of overactive patterns. Usually the more these muscles are used appropriately and strengthened in the new position the new pattern is ingrained and lasting change occurs and we move forward in our programs either in rehab or performance/strength training.

…But what if it doesn’t stick…

…What if you do all the right things, find the right position, put the muscle in a position where it should work, it is worked, but lasting change never happens…

…What then…

Budapest. The capital of Hungary is Budapest. I have now forgotten the capital of Luxembourg, Turkey and Switzerland (don’t judge me) but I will never forget the capital of Hungary. Why? In order for this seemingly unimportant information to stick I needed to give it meaning. I had to come up with a tool, or mnemonic, to get this information to stick in my head. A mnemonic according to Wikipedia (the source of all that is good and true) is partially defined as any learning technique that aids information retention in the human memory. Commonly encountered mnemonics are often used for lists and in auditory form, such as short poems, acronyms, or memorable phrases, but mnemonics can also be used for other types of information and in visual or kinesthetic forms. Their use is based on the observation that the human mind more easily remembers spatial, personal, surprising, physical, humorous, or otherwise "relatable" information, rather than more abstract or impersonal forms of information. The mnemonic I remember for the capital of Hungary is: “whenever my little brother is Hungary, he is nothing Budapest (get it… bood-a-pest)”. I am sure we all have used mnemonics to remember something and I can think of a lot more but this one really sticks out for me.
If our rehab or performance gains are stalling and the good work our muscles are doing is not sticking, or if the new pattern or memory of what is supposed to work is not sticking we need a PT mnemonic. For your body to engrain a new movement pattern, muscle activity needs to be coupled with a sensory (kinesthetic or even visual) component and a purpose. If the sensory input or purpose of any activity is either not felt, felt inappropriately, or distorted in its reality, the overall success of that activity to create lasting change will be significantly limited. If the sensory input and purpose is appropriate and correlates to a specific activity or movement, the success of that activity will be increased.
What might that look like in our programs? For some it may be just paying attention to a specific body part while doing an activity to create a reference that matches the activity. For example, make sure to push the right arch into the wall when doing a side-lying right glute max activity. This should improve the ability to feel the glute max better. Without this reference center the activity will be limited in its success even if the leg is in the right position and the exercise is performed correctly. Or it may be necessary to make sure that the person is consciously aware of the space and wall in their left peripheral vision while doing standing exercises balancing on the left leg. If the brain doesn’t recognize the reference of the space on the left side, there is no purpose for balancing on the left leg and learning a new pattern of left stance won’t happen successfully. There are many more cues and sensory references that can be used depending on the person and activity or desired outcome.
If the brain struggles to interpret the sensory input correctly despite appropriate references and cuing there may actually be a challenge that the brain has to interpret this input accurately which is why the output is less than desirable. There may need to be a change in the way and manner the input is received to force the brain to change its output appropriately. This could include intraoral appliances, PRI vision glasses, a change in shoes (or no shoes) or listening to different sounds or tones of sounds. People with sensory processing difficulties such as this are great candidates for PRI programs as traditional activities will be limited in their success. Unfortunately for some they may also need interdisciplinary integration. The PRIME program here at the Hruska Clinic is the premier place to receive this type of interdisciplinary treatment. We consider ourselves the Premier center for advanced clinical PRI Sensory Integration (click the map on our home page for more information on this). We are here for you when for all your efforts you and the people you work with are Hungary for more and sick of being nothing Budapest.