Torin's Blog


  • If you are working at home and sitting at a different desk than normal or just get right neck pain with sitting at your desk here is a quick video and tips from Torin about sitting at your desk.

  • Did you know we work with optometrists to assist some of our patients? Here are some frequently asked questions about why and when we integrate with optometrists here at the Hruska Clinic.

  • Download a pdf written here at the Hruska Clinic with some good tips on things you can do throughout your day to keep your body and its systems working in a more optimal fashion. If you have questions or need more fine-tuned tips feel free to contact us.

  • Read how socks, shoes, and squats helped Torin remember to not forget about the basics.

  • 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.

  • 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.

  • 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).

  • 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.

  • 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.

  • 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.

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

  • 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.

  • 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)

  • 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?

  • 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

  • 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 their arms, 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. Read how walking in circles can help us achieve this.

  • 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

  • Swimmers, Take Your Mark….Where do we start? Torin’s third swimming blog is here!

    If you’ve ever watched a swim meet, before every race the starter announces: “Swimmers, take your mark…”. Each swimmer then reaches down to the block to get ready to dive, or curls up if they are doing backstroke to get ready to explode into their race. They are putting their body into a starting position. In my last 2 blogs I discussed this interesting creature that we see that lives on land and thrives in water called a swimmer. I outlined different demands placed on a swimmers body based on the activity that they do, as well as the patterns and postures that are affected by those demands as well as the demands of just being a human. The next question is what do we do about it? Where do we start? How do we take our mark to get ready to explode?

    As we look at the effects that swimming has on a human body, which is designed for walking and running, and add the demands that we all have as asymmetrical humans, I see a few important things that need to be addressed. From my perspective as a PT utilizing the science of Postural Restoration®, swimmers need (among other things):

    a. Balanced airflow and chest wall movement in all directions
    b. Increased strength of hamstrings and abdominals to decrease extension tendencies (they may have different needs on each side of the body)
    c. Increased strength of glutes, lower traps, triceps, serratus anterior and rotator cuff muscles (subscapularis in particular) to counteract this very strong pattern developing in swimmers (remember the 14,400+ reps of pulling each arm does each week)
    d. A properly positioned and efficient diaphragm muscle for breathing
    e. Flexibility in hip flexors, back extensors, chest, neck, and external rotator muscles
    f. A high quality shampoo/conditioner to help with that straw-like hair

    So how do we get there? As I look at that list every item either contributes to or is influenced by one main need. (FYI it is not letter f.) The number one need that swimmers (and humans) have is letter d. The properly positioned diaphragm is how we “take our mark.” Without a properly positioned diaphragm balanced airflow and chest wall (which directly influences our spine) movement is impossible. When extension tendencies are too high limited hamstring strength and abdominal strength makes properly positioning a diaphragm impossible. Improper chest wall, spine, and shoulder blade posture from the strong pattern which is due largely to imbalanced breathing mechanics, limits strength of glutes, lower traps, triceps, serratus anterior and rotator cuff muscles. Again those muscles need to be strong to avoid injury (or so the research tells us). Without the ability to breathe with a diaphragm in the proper position, increased demands are placed on hip flexors, back extensors, pectoral, and neck muscles for breathing and postural support and they will get tight.

    Therefore the first thing I want to look at with a swimmer (human) is activities to enhance trunk flexion (back rounding) and trunk rotation with proper use of abdominals and BREATHING! Our swimmers must be able to fully exhale to get their bodies into a position where the spine and ribs and diaphragm are in an optimal position for efficient breathing and learn how to inhale from that state of flexion without going back into a state of extension. Remember that pattern of extension that we see in swimmers promotes back bending, rib(chest) hyper-inflation and poor diaphragm position. The first thing to break that pattern is to get rounded and air out. When I see someone the first thing I want to know is can they breathe. And not just breathe but can they fully exhale to get air out and put their diaphragm in a proper position and then use it to inhale without overusing neck or back (extension) muscles. I will have a swimmer sit on a 6-inch step, hug their knees to their chest as much as possible and see if they can blow up a balloon.

    (Hmmm… this kind of looks like a backstroke starting position)

    If they have trouble either a) getting into that position, b) exhaling fully into the balloon, or c) inhaling fully without using their neck (shrugging shoulders) or back (straightening the spine rather than keeping it rounded) I know they have a breathing issue that needs to be addressed first. This activity may now become their first exercise to do. Once we have that down I know we have a diaphragm that can at least get to an optimal position so they can take their mark. I don’t know if they can swim yet, but now we can start to train and address the other issues as outlined above as long as we can keep the diaphragm in that optimal position. Now we can start to explode and swim.

    We also may need to address any imbalances that we see to promote a more symmetrical system by checking to see if equal neck rotation, shoulder rotation and trunk rotation is possible. If there is an imbalance, the swimmer can’t blow that balloon up, or is struggling with an injury I would recommend consultation from a Hruska Clinic or PRI trained PT to develop a specific program for that swimmer. Feel free to contact me if you have any other questions.

  • Torin says: Swimmers (who are people too) are imbalanced creatures…

    In my last blog (Amphibians can be people too) I tried to describe an odd group of individuals with different needs and demands they place on their bodies…swimmers. By the end I hope this one fact wasn’t lost on anybody: Swimmers are in fact people. They are in fact still humans who need to breathe and walk and talk and deal with gravity and the “normal” world like all of us but for several hours a day they dive into near weightlessness and move themselves around with completely different muscles and movement patterns and reference centers than the rest of us do. I think that qualifies them as amphibians… who are people too. Now along with the straw-like appearance of their hair and the slight chlorine smell they may exude, they develop some different muscle patterns and imbalances than some of us do. My goal with this blog is to identify some swimming specific patterns as well as some human specific patterns. Once we know who we are dealing with, we can get better at treating and working with these unique people.

    When swimmers spend such an extraordinary amount of time and repetition pulling themselves around with their arms in an environment that requires them to hold their breath with a limited demand from gravity they will undoubtedly develop some patterns. In particular swimmers tend to develop a pattern of extension and hyper-inflation. Huh? A swimmers body that is driven into extension and hyper-inflation will tend to have a few common themes:

    a. Deep low backs (tight low back muscles)
    b. Elevated ribs in the front
    c. Rounded shoulders (from strong, tight pectoral and latissimus muscles, which are used for pulling) on a spine that is extending/backward bending)
    d. Forward head postures (that develop to compensate for the above)
    e. Weak glutes (due to deep backs and forward pelvises with strong, tight, hip flexors from kicking)
    f. Hyperextended knees when on “dry land” (from the forward pelvis and weakness in the glutes)

    These postural imbalances, which are causing or a result of a pattern of extension or hyperinflation, can lead to several potential muscle imbalances that we commonly see.

    a. Strong, powerful latissimus muscles. This is necessary for swimming power but unfortunately can limit rib cage expansion and rotation of the trunk through increased back extension. Increased extension of the spine limits the joints ability to rotate.
    b. Long, weak, improperly positioned intrascapular/scapular muscles that stabilize the shoulder blade (i.e. middle and lower traps and serratus anterior). These muscles, if weak, have been implicated in shoulder injury/impingement in numerous research studies. This single point is usually the only focus of rehabilitation programs for a swimmer.
    c. Strong powerful hip flexors and back extensors from flutter/dolphin kicking that are also positionally strong from being in prone. When these muscles become imbalanced with abdominals and gluteals/hamstrings proper pelvic and spinal position is lost.
    d. **Improperly positioned, inefficient diaphragm muscle (pulled up by ribs and down by hip flexors) that leads to poor rib expansion and overuse of neck muscles for rib cage support and breathing. This will restrict trunk and cervical (neck) rotation.
    e. Improperly positioned and long abdominal muscles (specifically transverse abdominis and internal oblique) for rib and pelvis stability as well as for trunk rotation.

    That’s a lot of great stuff to work on and it makes a lot of sense in terms of what we see when we look at swimmers and assess their needs and bodies. However getting back to the point I made at the very beginning of the blog: Swimmers are people too. So what does that mean? That means that they have to walk on land and breathe air most of the day. They also have a normal asymmetrical postural pattern of right sided dominance which is attributed to many things including organ asymmetry, neurological/brain dominance, and habitual daily activities to name a few. If you’ve read any of our other blogs I know this pattern has been identified and explained but if that doesn’t make sense I would just refer you to search the site and keep reading.

    This typical HUMAN pattern encourages this SWIMMER extension pattern we talked about above to potentially be more evident on one side of the body compared to the other. This imbalance, and how we choose to compensate for it, will usually restrict neck and trunk rotation and breathing efficiency more on one side of the body than the other. This will need to be addressed in addition to the above general swimmers needs. This means that reciprocal and alternating (i.e. back and forth, right and left) activity is a must to maintain as much balance and symmetry as possible. This is especially important with breathing and more so for swimmers.

    An easy tip that is a good place to start for all swimmers and especially young swimmers is to encourage bilateral or reciprocal breathing patterns as soon and as much as possible. What this means is that when swimming the freestyle or front crawl swimmers should breathe every 3 or 5 arm strokes to alternate the side toward which they rotate to breathe. Swimmers will often have a side that they prefer to breathe to. However it is necessary to develop this reciprocal/alternating breathing pattern or you may develop a lot of the issues that we talked about above. This may include limited trunk or neck rotation to one side over the other and limited shoulder rotation on one side or the other. This will limit the swimmers ability to pull water as efficiently with one arm compared to the other. They may start to develop a rib flare on one side more than the other which will affect breathing efficiency. All of these will lead to potential muscle imbalances which increase the likelihood for shoulder or back pain on land or in water and potentially decreases the efficiency of your swimming strokes.

    These postural and muscle imbalances need to be addressed as swimmers and as humans to maximize our ability to function normally whether we are swimming, walking, running, or breathing. In my next blog I hope to identify how we can use the science of Postural Restoration® to assess, treat and improve these imbalances for our swimming friends, no matter how bleached their hair may be. Please feel free to contact me if you have any questions or want more information.

  • Amphibians can be people too... or so says Torin is his latest blog!

    As some of you may or may not know I was a competitive swimmer in another life having swam competitively through high school and in college until I started physical therapy school. I was no Olympic athlete but enjoyed the sport and still enjoy it however my idea of a swimming workout usually consists of getting my heart rate up from catching my kids as the jump in the pool, and being a water taxi taking them from place to place wrapped around my neck, not swimming laps. Swimming is however one of those sports that unless you are involved in it only comes to the national attention about once every 4 years. Most people love watching swimming at the Olympics and admire the athletic abilities of the swimmers. When you have competed and can comprehend exactly how fast and efficient they are, it is that much more impressive. I recently was able to watch the Nebraska state high school swim meet on TV and felt the same way about our local swimmers. I can’t help but combine my passion for PRI and the way we work with all patients and relate it to swimmers. There are some issues that our swimming friends have that are unique to them, but underlying all that is still this normal human pattern that we see everywhere. These swimmers, amphibians if you will, can be challenging because they need to learn to manage their bodies in 2 completely different environments and with different demands in each. I thought I’d start a series of blogs highlighting swimmers and swimming as well as trying to relate it to those of us who prefer land as well.

    What swimmers need or do that is different.

    Today I thought I’d highlight some things that are different about swimmers that can challenge their management in and out of the water.

    1. Swimmers use repetitive arm pulling for power- using primarily the latissimus and pectoral muscles. Most other sports use legs for power. An average age-group (18 and under) swimmer may swim about 6000 yards per practice x 6 practices a week. If on average it takes them 10 strokes with each arm to go across a 25 yard pool that is roughly 14,400 strokes per arm each week. That’s a lot. (High level high-school and collegiate swimmers have much greater mileage than this) Imagine going to the gym and doing 14,400 reps of anything in a week.

    2. Swimmers spend more time lying prone (face down) than any other sport. This position encourages extension of the low back and spine.

    3. AIR: Swimmers must focus on breathing and breath control more than other sports because, well, breathing underwater is challenging.

    When swimming swimmers should breathe in through their mouth and out through their nose. (because sucking water in your nose sucks)— This is good when swimming but not on land. Out of the water we should breathe in through our nose and out through our mouth.—Why? This allows for proper and efficient use of primary breathing muscles. The opposite (what swimmers do in the water) encourages increased use of accessory muscles of respiration like your back and neck.

    Swimmers shouldn’t be “holding their breath” when they are underwater-but probably do. Holding your breath promotes extension and hyperinflation. They should have a slow steady exhale as their face is in the water.

    Due to these factors, some swimmers “learn” to either a) breathe with improper muscle use (in thru mouth out thru nose) and continue this when out of the water or b) learn to function in a state of extension and hyperinflation leading to altered breathing mechanics and postural alignment.

    4. Swimmers need to worry about drag forces in the water- staying streamlined to go fast requires maximal shoulder flexion.

    5. Swimmers don’t need to worry about gravity when they are in the water, and it is a very freeing sensation if you are a good swimmer.—This means they don’t have to use their glutes as much… yet they need them desperately.

    My goal over the next few blogs is to outline what these extra demands swimmers have along with the demands “normal” humans have do that challenges us as clinicians. After all, those swimmers need to get on land at some point. I also hope to try and explain how to take these factors into consideration to have more success as a swimmer or when treating or training a swimmer. Please feel free to contact me if you have any questions, or desire to learn more about it. I’d love to hear from you.

  • The True Missing Link? Torin might know the answer to this in his new blog…

    In my last blog I wrote about how here at the Hruska Clinic we try to find the missing links for our patients, whether that is addressing their pelvis position to finally solve a shoulder problem or to refer to a podiatrist or optometrist or dentist to help a person function to the best of its ability. Our goal is not to just look at a symptom but to put all the pieces together to get to the root of the issue. I had to really work hard in that blog to avoid using some fun missing link clichés; “you are only as strong as your weakest link”, or reference an old game show… “You are the weakest link… Goodbye!” or somehow get some kind of Sasquatch reference in there but I did. Obviously since I started there with this blog I just couldn’t resist a second time.

    Today I wanted to talk a little about a common missing link that we see both in traditional PT treatment strategies for our patients and in literature or research devoted to rehabilitation. That is a little thing called a ribcage. A lot of PTs and patients for that matter can see the relationship of how you need a strong hip and leg to throw a ball or swing a bat, and if you don’t have a strong push off those types of activities will be challenging no matter how strong your shoulder or arm is. Try throwing a ball without shifting your weight from one leg to the other or moving your feet to see the importance of leg strength for arm function. It is not uncommon, therefore, for athletes, and trainers, and PTs to spend some time developing leg and hip strength to help with throwing and swinging activities. People will even discuss chains of muscle that show how the power of the hip helps drive the body so the arm can move with more speed or power. What a lot of people don’t understand is that that same transfer of power from the ground up is there for every activity we do whether, getting out of a chair, walking, or reaching overhead to put the groceries away on the top shelf of the pantry. Unfortunately commonly this little thing called a ribcage is usually missed or glazed over both in treatment and in education of PTs and trainers and is a vital part of this transfer of energy from the legs up to the arms (or vice versa). If the position, flexibility and strength of the ribcage and its muscles are not addressed we missed a link in the chain. If you truly are only as strong as your weakest link (you knew it was coming didn’t you?) that rotator cuff or hip problem won’t really matter unless that rib cage is addressed.

    So what do we look for? The ribcage is often just seen as the protective bones around our lungs and heart that gives our torso its shape and stability. That is true but the rib cage function is directly linked to 2 other important activities namely breathing and movement (especially rotation) of the mid spine. Your diaphragm muscle, which we have talked about a lot on our previous blogs, attaches on the front, lower part of the ribcage and makes a parachute shape as it sits underneath our lungs and heart and attaches directly to the lumbar spine and into the hip flexor muscles. As we take a breath of air in our diaphragm contracts, descends, and the rib cage expands (or externally rotates) as the lungs fill with air. As we exhale the ribs descend (or internally rotate) the diaphragm domes back up and air comes out of our lungs (we use abs to help if this is forceful). Due to the ribs attachment directly to the spine as the ribs rotate down or up the spine flexes (rounds) or extends (straightens). If we twist our spine to the left, because of the direct attachment of the ribs on the spine the ribs have to elevate, externally rotate, and expand on the left and descend, internally rotate and compress on the right. This means that the left ribcage is in a state of more air in, or inhalation, and the right is more in a state of exhalation. The opposite holds true when we rotate our spines to the right. When we walk or run and rotate our trunk as we swing our arms this should happen equally with each step we take.

    Now unfortunately we are not built and don’t function symmetrically because of lots of factors which have been written about before, but for the purpose of the rib cage this includes a heart that lies more in the left chest wall than the right keeping it more open, a liver under the right diaphragm that keeps it domed up better than on the left for efficient breathing, and a bigger stronger diaphragm muscle on the right side with more and stronger attachments on the spine. Because of all of those factors, just the act of breathing (and contracting the diaphragm) pulls the lower spine to the right (thanks a lot strong right diaphragm), expands the left chest wall better than the right (thanks heart and efficient right diaphragm) which directly rotates the mid spine to the left. This is our normal pattern and becomes ingrained and normal in us just by breathing. This is why it is common to see rib flares in the front of the left rib cage when lying on your back and more evident rib humps in the back of the rib cage on the right. If this asymmetrical pattern and position of the ribcage is not addressed, rotation through the mid spine will be asymmetrical, the position of the ribs and therefore any muscle attachments will stay asymmetrical and function will be less than optimal and injury may ensue or perpetuate. (In my best British accent: “Rib Cage: You ARE the weakest link… Good-Bye!”)

    Here at the Hruska Clinic we feel that instead of the rib cage being the weakest link it can be the strongest link if we make sure that abdominal activity is maintained and equal (the left side needs a little more attention to keep the front ribs down and diaphragm domed up) and the ability to expand the rib cage is equal (usually needs to be addressed on the right side due to position and limited internal stability). We may choose to address this with manual or non-manual techniques depending on the specific needs of our patients. If that link is addressed first the whole chain will be stronger and we can fully help the body function as a whole unit for swinging a baseball bat, walking, putting the groceries away without injury, or running through the woods chasing after a Sasquatch to get the elusive picture of the true “missing link”.

  • The Missing Link - Here is Torin’s new blog!

    Every now and then in our lives we have times when we just know that something is missing. There is a missing piece of the puzzle or link in the chain, or somehow the chain just doesn’t seem connected as it should. The more experience I gain in life as a person and as a PT leads me to believe that finding these missing links in the chain of life can make all the difference. For example in PT school we are taught the body and how to care for it piece by piece. I learned a lot about the shoulder, and the neck, and the back, and the hip, the knee, the foot, on and on… separately. I understand why, because the human body is such an amazingly complex machine that to try and understand it as a whole first is very difficult, so we learn by studying all the pieces. I never was really able to put those links of chain together until I started to study and understand the principles taught through the Postural Restoration Institute (PRI). This theory links and explains how all the pieces have to work together to work and function properly. It also adds a few links that were missing including the diaphragm muscle and this little thing called a rib cage that we all but skipped over in school to study the more important things that we see that have pain like shoulders and knees. Never did we even think that the way you can or cannot breathe WILL have an impact on how those other structures work. I now know that if all I do is look at the shoulder link and never look at the other links my chance of long term success is limited. We have written lots of other blogs on why these things are important and I may continue to come back and address some of these missing links, like the diaphragm, rib cage, pelvis position, pelvic floor muscles, footwear, tooth contact, vestibular system and balance reactions to name a few, as to how they WILL affect my patients ability to get better.

    However the more important chain that I also wanted to touch on today is the link not only within each of us connecting our toes to our head, but in the links between each of us. In our current healthcare model I see a lack of interconnectedness between disciplines. We have lots of strong links in the medical community, dental community, chiropractic community, PT community and many more but no one connects those links together. Probably the best example we can draw for an interconnected medical community is the Mayo Clinic model, where if you need help from them you will go and spend a week and see whomever you need to see and a plan of care will be established. You won’t see just one doctor, you will see as many as you need, and all the tests you need will be done, and a comprehensive plan will be set up. Here at the Hruska Clinic we try to use this same sort of model (that we call Interdisciplinary Integration)to help our patients out. Many of our patients have tried numerous other options (one at a time) and had varying degrees of success. What makes us different is that we will recognize and recommend through a comprehensive treatment plan all the needs of our patients and refer or consult with whomever we need to get the job done. We may need our patients to see a podiatrist, or a dentist, or an optometrist, or a chiropractor, or a massage therapist, or get a different pair of shoes or pillow or chair at work. We want to connect and utilize all the strong links we have available to us to help our patients out and we are committed to this comprehensive plan of care. That is what you will get at our clinic and we hope to get your chain(s) connected.

  • Put It Back!!! Torin (and his wife) suggest making this action a habit in your life…

    As a parent with 4 young boys, 3 of whom are old enough to make a giant mess, things can tend to get a little disheveled at our house. My wife (who has 4 boys old enough to make a big mess) and I are constantly saying “Put It Back!” If you play with a toy… Put it back! If you ride your bike… Put it back!! If you get out a game to play, or ball to play with and are done with it… Put it back! If you make a sandwich and leave the peanut butter out… Put it Back!! OK so that last one was for me, but you get the point. It doesn’t seem like a hard concept, but for our kids (and sometimes for myself) it is a challenge. When we never put anything back our houses and lives can start to become chaotic and hard to get around in. The messes pile up and eventually, if we don’t intervene, there is only one path to get through the house, if at all. I would reference some scenes from the TV show “Hoarders” but I think you get the point.

    It may be a bit of a stretch but our bodies can be seen in the same way. We are constantly doing activities in a certain pattern (usually with an underlying Right side dominance) and our brains become accustomed to that one pathway of doing things. Our goal with treatment here at the Hruska Clinic is to not let that one pathway become the only way to get around the house, but to put your body back into a position that allows you to use whatever pathway you want to get around. If we are not vigilant in constantly telling our bodies (or kids) to put it back where it belongs then the pathway to accomplish an activity becomes narrower and narrower and the chance for injury increases. So we are constantly encouraging our patients to do activities in a pattern different than the normal pathway. For example, it is inherently easier for us to stand with more weight on our right legs with our pelvis and spines pointing to the right than to stand with weight on our left legs with our pelvis and spines pointing to the left. If all we do all day is stand on our right leg and never put our body back into a neutral position then eventually we lose the pathway or ability to shift our weight to the left without compensating or without pain. As a patient here it has probably been suggested to you to stand on your left leg some, or sit and find your left sit bone, or look to your left with your eyes, or some sort of activity to “Put it back.” The point of those activities or reference centers is to keep your body cleaned up and neutral so your pathway is clear and you can move around without tripping over something.

    Another example of putting it back comes when we suggest to patients to do their exercises, or a particular exercise, AFTER doing something like running or working out. Take running for example. It is an activity, typically in extension, that has a pattern to it. You don’t have to think about running, you just run. So every time you run you engage a specific set of muscles, in a specific pattern, to accomplish it. This pattern may have been a balanced, symmetrical set of muscles equally using the left and right sides of your body with appropriate activation of glutes and abs to counter the extension muscles (back and hip flexors) that are pushing you forward, but most likely not. It’s not necessarily bad to do an activity that will pattern your body a specific way to accomplish it, whether running or swinging a golf club or hitting a volleyball, just make sure you do an activity or exercise to Put it back when you are done. Flex, reach, or do something to go backward after running forward, stand on your left leg and turn your body to the right after throwing a ball (pushing off your right leg and turning your body to the left). Just Put it back when you are done so that your pathways are clear and your body does not become stuck in one pattern to function.

    As my wife says… It’s not bad to get the peanut butter out to make a sandwich, but PLEASE, PLEASE Put it back when you are done!!! (Thanks, honey for keeping me balanced) :)

  • The Olympics: Celebrating human achievement. Torin explains the marvel of the Olympic Athlete…

    I love the Olympics. I could sit and watch them just about all day long. Anytime you can watch the best in the world do what they do it is impressive. Whether a gymnast doing a balance beam routine or tumbling pass, or a volleyball player jumping a mile high and hitting a ball, or an archer with the concentration and stability to hit the bulls eye on almost every shot, or a swimmer that makes such speed look easy, the ability of the human body is amazing to watch. As a former swimmer the Olympics is about the only time that sport really gets great coverage and we can see the athletes perform at the top of their game. It makes me a little nostalgic for jumping into a cold pool… but not really.
    As a physical therapist, and specifically a PRI trained PT, I can’t help but marvel at the way these athletes have trained their bodies to perform such specific activities in specific patterns and can do it at the level that they can. How can a swimmer swim 6000-10,000 meters a day 5-7 days a week (at 8-10 strokes per 25 m this equals about 20,000 repetitions of arm stroke per week) for years without completely destroying their shoulders? Or how can a gymnast do hundreds of back handsprings and splits a day for years and not tear up their back or hips? Or how can that archer stand in one position at full concentration to practice archery for hours at a time day after day without injury? Obviously some of them can’t. They will blow out their shoulders or backs or hips or necks, and we don’t see them in the Olympics or get to know their names at all. Why do some make it and some don’t?
    From my perspective I hope that those athletes spend a lot of time trying to minimize the influence their training habits and patterns have on the rest of their body. I hope that swimmer, that has to have extreme pulling strength and hip flexor strength for kicking, also has good reaching and glute strength to keep those strong muscles from putting that swimmer’s pelvis or shoulder in a position that risks injury. I hope that archer that stands with his body (ribcage) rotated one way and his neck the opposite way to see his target does a lot of activity in the opposite pattern so his respiratory diaphragm and ribcage is in the right position for him to breathe without his neck doing most of the work (see my blog on diaphragm position here). I hope that gymnast who has excessive hamstring length and back extension flexibility has the strength in her hamstrings, glutes and abdominals to prevent lumbar spondylosis (see Dave’s recent blog here) or hip pathology.
    I hope you all marvel at the incredible feats of the human machine during these Olympics as I will be doing. I also hope you marvel at the incredible feats your own body is doing everyday so you can sit at that computer and read this blog (and breathe at the same time), or carry that newborn baby, or whatever it is that you do on a repetitive basis all day long. I hope also that whatever you do you are performing some activity to keep your body in a balanced position so you can keep doing it without blowing out a shoulder, or back or hip or neck. Your computer time may be just like that archer and you need some activities to allow you to “compete” at your job without your neck or head hurting. Your standing job may require you to have hamstring and abdominal strength to keep your back safe just like those gymnasts need. We all have an amazing human machine, let’s let the Olympics allow us to all marvel at the incredible feats we do everyday… even if there isn’t a gold medal for all of us.

  • Such a pain in the neck… No, not Torin, but his latest blog!

    One of the most common complaints we hear here at the Hruska Clinic, or anywhere for that matter, is neck pain. It may or may not be a primary complaint but who doesn’t know the feeling of that tight knot on the top of your shoulder blade that just won’t go away, no matter how much you rub it or stretch it. Or how about that tight feeling at the base of your skull when you try to turn your head from side to side. These 2 things can be frustrating to deal with as a patient or as a PT if you don’t look at the whole body because if you try to just treat the neck or shoulder without first making sure the position is where it should be, you really have a limited chance of fully fixing the problem.

    In my previous blogs I talked about specific muscles that we want to be in the right position to function properly, namely the diaphragm, and indirectly, the abdominals. Today I want to talk about making sure your neck and shoulder blade are in the right position to function properly. The poor upper trap area gets such a bad reputation these days as literally such a pain in the neck. Wait… bad reputation… “that thing is killing me!” you might be saying. How can you feel bad for that muscle? Well, the thing is that muscle has no choice but to be tight and knot up because of the position it is in. It is almost literally hanging on (to your arm) for dear life. No matter how much you massage it or ultrasound it or acupuncture it or try to beat it into submission it just tightens up again. Instead of beating your head on a wall (that won’t work either) let’s put it into a better position and give it some help and see if it can relax that way.

    The best way to get your neck muscle in a better position is not to look at the neck but to look under the neck to make sure it is in the best position to function. The neck is kind of like our fifth appendage in that it is attached to our trunk, just like our arms and legs. So to make sure the neck is in the best position your trunk needs to be in the best position underneath that neck. Our normal patterns of function that we address here at the Hruska Clinic with Postural Restoration techniques identify common patterns of extension (tightness) on one side of the body or both. We have talked about that in the pelvis and low back. Above the pelvis, the same thing happens in the rib cage as a direct compensation for the pelvis position. As we try to function with an asymmetrically positioned or extended pelvis we extend our back and the thoracic rib cage becomes straight and restricted in its ability to expand in the back on one or both sides. This position of the rib cage, which you can visibly see as either an anterior rib flare on one or both sides or a posterior rub hump, directly alters the position of the shoulder blade as well as the position of the base of the neck (either forward or rotated). These 2 factors place increased demand on our neck muscles for respiratory function, and limits the ability to use muscles of our trunk to stabilize the shoulder blade due to the improper position they are in. All of this leads to overuse of the neck and upper trap/levator scapula region. There are lots of reasons why this would happen on one side or the other which is beyond the purpose of this blog but there is a definite influence.

    So how do we deal with it. The best way to help relax a neck is to make sure that the rib cage and shoulder blade is in a proper position. One way to do this is by learning to pull ribs down in the front with abdominals (exhaling fully), breathing in with a diaphragm muscle that is now in a proper position (see my last blog) and expanding the rib cage in the back underneath the shoulder blade so it has a place to rest without need for extra muscle activity. Try this. Sit towards the edge of your chair and round your back so you can rest your forearms on your thighs. Take a nice breath in through your nose and blow all your air out while you push your forearms gently into your thighs and keep your back rounded. You should feel your abdominals contract. Now keeping your abs engaged or tight, take a slow deep breath in through your nose and concentrate on filling the back of your chest wall (between your shoulder blades) with air. You should feel as if air is pushing your upper back towards the back of your chair while keeping your forearms on your thighs. Repeat this for 4-5 breaths and relax. If you can’t feel your abs or feel your upper back expand, or if you feel your neck tighten to get that breath in, there may be other things we need to address to help you out. Otherwise this is a great activity to do to keep your abs working, to put your ribs in a better position, to put your diaphragm in a better position, to expand your rib cage, to put your shoulder blade and neck in a better position, to help relax that darn knot. Boy that does a lot, doesn’t it! If this doesn’t help you out let us know so we can help you address other influences that may be keeping your neck in an improper position and tight.

  • Breathe well and live well… Check out Torin’s latest blog!

    For breath is life, and if you breathe well you will live long on earth. ~Sanskrit Proverb
    Learn how to exhale, the inhale will take care of itself. ~Carla Melucci Ardito

    I thought I’d share just a few quotes I found on breathing. If you have been a patient at the Hruska Clinic or with a PRI trained PT you know that we have a strong passion about breathing. We truly believe that if you breathe well not only will you live long on earth, but that you may be able to live better on this earth.

    Of all the things in our lives, if you break it down to the bare minimum to sustain life, what do you really need? Food, water, air, shelter, protection. Obviously if I were living in the African plains I think protection from lions might be pretty high on that list, and if I was still living in North Dakota in the wintertime shelter would be up there as well. But for our bodies to stay alive we can go several weeks without food and several days without water before they shut down. But go without air for even a few minutes and the damage is done. Thus, in an obvious sense if you stop breathing you’re not going live long at all. But just breathing to sustain life says nothing about the quality of breath, and thus nothing about the quality of life.

    In my last blog I shared the ‘secret’ of position. The secret states that muscles need to be in the proper position in order to function optimally. The first muscle I want to specifically talk about position with is the muscle that can help us out with the quality of our breath (and therefore life). That muscle is the diaphragm.

    I just wrote that the number one thing we need to do to sustain life is breathe. Every cell in our brains knows this, and therefore everything else, including how bad our back, or neck, or head, or jaw might hurt, doesn’t really matter that much. Above all else get air in. Keep me alive. When we get in dysfunctional patterns or positions and the efficiency of our breathing becomes challenged our brains will do whatever it takes to get air in. Even if it reinforces patterns or positions that create pain. Our brains would sacrifice a tight, painful neck or back to be able to breathe. So if all we do as therapists is try to stretch out or relax that neck or back muscle that is just trying to help get air into our lungs without first giving the body a better way to get air in, all we are doing is making life harder for them. We may be literally taking away their ability to get air into their lungs. Fortunately for us the brain won’t let that happen so it will just keep tightening that neck or back and at best our treatments will just look like they aren’t working. Conversely, if we teach that body a new, more efficient position or way to breathe or exchange gas it will hold onto that new pattern very strongly. If that new pattern or position includes the diaphragm muscle the brain may just tell that tight neck or back, “I don’t need you anymore, go ahead and relax.”

    So what is that position? The second quote above helps us understand that more clearly. There have been a lot of blogs on our website about the diaphragm and breathing mechanics. Please search the Hruska Clinic website for more specifics and enjoy. The main point I want to get across is that we need the diaphragm in the correct position to work efficiently. That position is what we call having a maximal zone of apposition. This is when the anterior and lateral ribs are maximally pulled down and therefore the diaphragm is maximally domed. This position requires posterior pelvic tilting, thoracic and lumbar flexion, and upper rib cage flexibility among other things. If we can get into this position and fully exhale, the diaphragm can be reset by pausing for 4-5 seconds and letting our brain (that wants air) send a message to the primary breathing muscle (the diaphragm) to please get some air in, and inhalation can happen with a muscle that is in its optimal position to work. This is what we really are trying to achieve with our techniques that require full EXHALATION such as blowing up a balloon, or through a straw, or while reaching forward and flexing the spine: Proper position of the diaphragm. No need for help from that neck or back or hip. As that efficient breathing pattern, with a diaphragm, is relearned our brain will like it and grab ahold of it, because there is no bigger need in our life than air. This is when our treatments will have success.

    My version of the quotes above says this:
    Learn how to fully exhale to put your diaphragm in a proper position. This will allow you to breathe well and live well.

    Please feel free to contact me with any questions. Have a great day!

  • Torin shares the secret on - The Importance of Being in the Right Position….

    Spring has come (and gone?) to Lincoln, NE and with that comes sporting events. Our oldest son, who is in Kindergarten, just started recreational soccer and I have volunteered to be the coach of his micro league soccer team. It’s great fun and I don’t know who is having more fun, the kids or myself. Micro soccer is basically 4 on 4 soccer with small goals and no goalie to give the kids all a chance to kick the ball and have fun. And it works. The kids all get involved and a chance to contribute and play and I think it is great. Back when I was younger I played soccer and even coached my younger brother’s teams when I was in high school so I don’t feel too lost… older but not too lost. If you have ever watched kindergarteners play soccer you will appreciate the game play as basically a mad, chaotic rush or amoeba-like conglomeration of 8 kids swarming after one ball until it finally gets kicked free and then they all run after it. This continues back and forth until either the ball goes out of bounds or into one of the goals. Usually if one kid gets free with the ball he can outrun everyone else and score an easy goal. At our first practice I gathered the kids in and asked them if they wanted to know the secret to scoring lots of goals in micro soccer. Of course since it was a secret they all desperately wanted to know. The secret is for all of the players to stay in their position and wait for the ball to get passed to them. Since the other team’s 4-headed amoeba will be chasing the ball, as soon as the ball comes loose our players should have a nice easy pass to an open teammate or path to the goal to score. If we keep one player to stay back and be defense if the other team should get loose there is always someone to be in the way to keep them from scoring. Easier said than done of course. It isn’t easy to get 5 and 6-year olds to do this, or just to refrain from grabbing the ball with their hands every time it comes to them for that matter, but it is a great goal to have. Of course the main goal is for everyone to play and have fun, but if we can keep everyone in the right position they will have a much better chance for scoring goals.

    Every day with our patients here at the Hruska Clinic we are constantly trying to get our patients to get their muscles into the right position so they can be effective at doing their jobs which in turn allows our bodies successful at doing their jobs. This can be anything as simple as breathing properly or as complicated as playing volleyball or soccer. This focus on first making sure muscles are in the right position before progressing with a rehab program is one of the main things that makes our clinic different and successful. If any muscle is in the wrong position it will never be able to be as strong or effective as if it was in the right position. For example let’s look at the muscles that we use to squeeze our hand into a fist. If you bend your wrist back as far as you can and then try to make a fist and squeeze as hard as you can you will find your grip strength is fairly poor. Then bend your wrist all the way forward and try to make a fist. Even worse… you probably can’t even get your fingers to touch your palm. There is a certain position of your wrist that optimizes the strength of the muscles that give you grip strength. Occupational therapists that manufacture splints can tell you probably the exact specific angle or degree of what that position is to optimize grip function. It doesn’t matter how much or how long you try to strengthen your grip muscles if you do it in an improper position. Your grip will never get as strong as it could just by putting your wrist in the proper position. This holds true for every muscle in your body which is why we feel so strongly about making sure your body is in a neutral or optimal position for muscles to function the way they should. Just getting into a good position will have more benefit and results than months of training in a wrong position. We will seek to find whatever it takes to put your muscles in the proper position, whether that is using specific exercises, manual techniques, foot orthotics, intra-oral appliances, braces, glasses, or duct tape and chicken wire if it works (just kidding). We will do this because we know that if we don’t the rest of our program will ultimately not have the success we want. In my next blog I plan to describe some specific muscles that here at the clinic we are constantly challenged to get into the right position to function properly and how we might address that with our programs.

    After 2 soccer practices and games we seem to have the defensive position figured out and already the kids saw what a difference that makes. My next goal is to get the other positions figured out and then… look out YMCA Kindergarten boys Micro Soccer league… we’ll be unbeatable. Ha! Wish me luck!

  • 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?

  • Smunching: The New Craze? Find out what Torin is talking about in his new blog!

    As you may or may not know I am a fairly recent transplant here to Lincoln. I grew up in Colorado Springs, CO. Obviously here Big Red football dominates but as I was growing up John Elway and the Denver Broncos was where we invested our loyalties. I still have to root for the Broncos and this year has been fun. Whatever your opinions of their quarterback Tim Tebow are, he has been the big story in Denver and throughout the NFL. A new word has entered our culture because of Tim. Tebowing. It is the act of getting down on one knee and praying, usually with head bowed on a hand or fist as Tim frequently does on the football field. It is now an internet craze where people will have their picture taken in that position in random locations. Google Tebowing for some fun pictures.

    Recently, I have come up with a word for an activity that we like to do in the clinic with our exercises. Smunching. Or smunch for short. I looked it up online to see if it has other meanings and apparently it is used by a group in Phoenix to describe eating a Saturday morning brunch. So I guess I can’t trademark it. I like it though. Smunching. It just rolls off the tongue. To me it is part smush and part crunch and describes a movement where you bend your trunk sideways bringing your ribs down toward your pelvis. As therapists we call it side-bending or thoracic abduction. It requires a contraction of your lateral abdominal oblique muscles and is something we encourage on the left side with PRI exercises. Left lateral abdominal muscles (including internal obliques and the transverse abdominis) are very important, wonderful, and yet too often underused muscles that can make or break someone’s success or recovery with a PRI program. They are the next muscle that I want you to be able to feel. Can you feel it? Smunch. How about now.

    It is not exactly news that abdominal muscles are important for “core stability” or back stability. What is often missed in traditional exercise or rehab programs is the need to address and correct differences in the position, function and use of muscles on the right and left side. Our philosophy here at the Hruska Clinic identifies and describes a normal, asymmetrical pattern of function. If you have not read much about that I recommend reading some of our other blogs here or on the Postural Restoration Institute website. This pattern describes a tendency to stand and shift our weight more on our stronger, dominant, stable right leg than our left leading to a tendency for the pelvis to drop forward on the left and orient or point to the right. Imagine if there were headlights on the front of your hip bones. In this pattern our headlights tend to point more into the ditch than into oncoming traffic. However, in order to reach with our more dominant right arm and look at oncoming traffic with our eyes we will rotate our upper body back to the left to compensate. When this pattern becomes too active or strong we can run into trouble.

    The last 2 blogs I have done described using the left inner thigh and left glute med to line the pelvis back up and get our headlights pointing straight ahead. Unfortunately what has happened above the pelvis in that pattern (the need to always rotate the spine left) has had some impact on function above the pelvis and needs to be addressed. As our spines rotate to the left to reach with our right hand to drive our car, or use the mouse of our computer, or realign our bodies with the direction we want to walk, the rib cage rotates into a position where the right ribs come down toward the pelvis and are anchored with right abdominals, while the left ribs are rotating up and away from the pelvis. The left abdominals are not working and being lengthened which decreases their advantage to work even if we wanted them to. These left abdominal muscles then become weak in their ability to do several important things for us. They lose their ability to stabilize the pelvis on the left side so it won’t drop more forward. They lose their ability to laterally bend the trunk to the left (smunching to the left if you are paying attention). And probably most importantly they lose the ability to pull the left lower rib cage down and stabilize it so the left diaphragm muscle has an advantage to contract and pull air efficiently into your lungs (maximize the ZOA on the left side for you therapists). The left abdominal obliques, and the ability to smunch or get into thoracic abduction to the left, is of utmost importance to make sure the hard work your left inner thigh and left glutes are doing for your pelvis continues to work, as well as to help correct the compensation your upper body has had to do because of the normal positional shift of the pelvis to the right. The abdominals are what is going to integrate or coordinate what your lower body and upper body are doing so they can work together to do things like walk, and run, and go up and down stairs, and breathe, or do any reciprocal activity without excess strain or falling back into old patterns. In our normal pattern the right ribs and muscles are already smunching so we need to really emphasize the left side to create a functional balance.

    Many of our exercises emphasize smunching on the left side by either reaching the left hand down towards your feet, arching the left side up when lying on the left, or even passively just positioning you to bend your trunk to the left. You should be able to feel it. But what if you can’t. Probably the most common reason for not being able to feel it in any position is a tendency to use your left back extensor as the muscle to smunch. It will bend your spine to the left but will also extend your back. If you are smunching and you feel your back make sure you round your back a little more and keep it rounded as you smunch. As we talked about earlier the abdominal muscles pull your ribs down which is what happens when you exhale or breathe out. If you hold your breath or are in a state of inhalation your abdominal muscles will have a harder time contracting so another trick is to fully exhale and feel your ribs go down. We will even use balloons or straws to resist the exhalation to feel the abs work. The key is then to try and maintain that feeling as you use your diaphragm to breathe in. If you lose your smunch when you breathe in we are never going to get anywhere. Sometimes when lying on your left side it can help to roll up a towel and put it under your left side to give yourself a feeling of where to smunch. In standing or squatting if you let your back extend and your pelvis drop forward you will stop feeling your abs and the back will take over. Think about reaching your knees forward as you squat to keep the pelvis tucked and abs on.

    I can only hope that smunching (to the left) will become as much a craze as Tebowing has. But until we get a polarizing athlete to do more smunching I think Tim will have a definite edge. I personally am still going to try and see if we can make it a craze one patient at a time. If you all get creative feel free to send or post some smunching pictures and maybe we can start this craze and help people all at the same time!

  • Can you feel it: Part Deux—The Left Glute Med. Read Torin’s follow up to his ” Lion King” blog…

    In my last blog I wrote about feeling the love of the left inner thigh muscle with PRI exercises to help with our ability to shift our body weight to the left to achieve and keep a neutral position of our pelvis. Hopefully you were able to feel your left inner thigh while shifting your weight from side to side as you stood in line buying (or returning) those last minute Christmas gifts. I also hope that the abundance of holiday music like “I’m dreaming of a White Christmas” or “Jingle Bell Rock” on the radio and in the stores helped clear the chorus of “Can you feel the love tonight?” from your mind.
    As we shift (get it?) into a new year I want to shift to a new muscle for this blog. One of the next muscles that we usually emphasize with our programs is the left gluteus medius, or glute med. This muscle has several important functions that are desirable in having success with a PRI program. These include turning the thigh bone (femur) in (internal rotation), and probably more importantly stabilizing the pelvis over the head of the femur once we have achieved the proper shift into the left hip with the left inner thigh (adductor) muscle. This is especially important in standing positions and walking to allow us to keep that proper weight shift to the left and not revert back to the overactive tendency to stay shifted to the right side. If the glute med is ineffective, due to improper position, or weak, your ability to maintain a neutral pelvis with upright activity or walking will be challenged. That is why our exercises will progress from just finding and feeling the left glute in a lying down position gradually to an upright position when your therapist feels you are strong enough. If this is progressed too quickly and the left glute is not felt or strong enough pelvic neutrality will be lost and our program will stall and so will your recovery. So let’s make sure you can feel it…
    If the glute med is appropriately working, it should be felt on the side and back of your hip behind your hip bone (think of your left back pocket), not in front. If you do not feel that muscle work when we want it to there are a few hints that we give to help you feel it. First of all you need to be able to fully shift into your left hip with your left inner thigh, so if you cannot feel your left inner thigh you will be challenged to feel your left glute med work properly. Therefore, all of the issues that can prevent you from feeling your left inner thigh may prevent you from feeling your glute. This includes things like hip capsule flexibility, right inner thigh over use, and lack of right chest wall mobility. See my previous blog if you need reminders. There are a few other issues I want to high-light specific to the left glute med.
    The muscle on the side of your hip in front of the hip bone (the tensor fascia lata, or TFL) will commonly try to help internally rotate your thigh bone instead of your glute if it (the glute) is in an improper position or weak. If the pelvis is forward, as is common on the left side, the TFL becomes better positioned than the glute to turn the thigh bone in and becomes overactive. It also will flex the hip and pull the pelvis further forward limiting the ability to keep the pelvis in a neutral position. This is not what we want, so the TFL is not a muscle we want to feel with any exercise that requires turning the left thigh bone in. So if you feel the front of your hip working when you turn your left thigh bone in we need to do something to stop that. First of all we need to make sure you are in the proper position (fully shifted into your left hip, left knee/hip back behind your right). Then, in order to shut off the TFL, we sometimes will cue an active isometric contraction or muscle squeeze into hip adduction and/or extension by either squeezing the left knee down into the right or pushing the left thigh back into a chair or door frame prior to rotating the thigh bone in. This should help.
    Another important thing that may help is to make sure that your left ribs are fully pulled down with your left abdominal wall (full left ZOA for you therapists out there) to achieve full stability on your left side and maximize the proper position of the left pelvis and glute. This will be highlighted more in my next blog.
    As we stated above the left glute med is important for hip stability in standing and walking positions. Once you have adequate strength in a lying down or seated position we need to get you to feel the left glute work in a standing position. The most important factor is to make sure that you have achieved a proper standing hip shift back into your left hip with your left hip back, your right hip forward (pelvis pointing to the left) with weight on your left leg (left AFIR position) and without extending your back. If you are not in that position your glute will not be in the proper position and you will not feel your left glute work as effectively as possible. One of the cues in stance that we use for this is similar to the left adductor in that we want you to feel your right shoe arch when standing and shifting to the left to inhibit the right adductor and allow the pelvis to fully shift to the left. This is one of the reasons why proper footwear and foot position is so important with upright activity. Don’t transition to a single leg activity on the left leg until you are fully engaged and into the proper position or your glute and program will be challenged.
    If you are doing your exercises at home and cannot get your left glute to engage or your front hip to relax during exercises aimed for your left glute med be sure to let your therapist know so they can help you find a way to feel it. And hey, no corny song that will get stuck in your head this time. Besides, the only one I could come up with for the glute was Sir-Mix-A-Lot’s “Baby Got Back…” Oops… sorry.

  • Torin wants to know: Can you feel the love, tonight?

    This past spring my wife, Leslie, and I went to Las Vegas on a little get-away trip and left our kiddos home with Grandma and Grandpa. At that time we were coming out of a long winter in North Dakota and just needed some sunshine and warmth. We spent a LOT of time at the pool soaking up the sun and relaxing. We had been there before so didn’t feel the need to walk the strip too much and it was very relaxing. The highlight of our trip, however, was getting a chance to see ‘The Lion King’ musical before it left Vegas. Yes I know, we took a vacation to Vegas, without kids, and ended up seeing The Lion King. It might sound a little pathetic but it was great. If you have never seen the musical I highly recommend it. The sets were amazing, the costumes…amazing, the singing… amazing. Of course the song we all remember from the movie was Elton John’s “Can you feel the love, tonight?” I know you all can hear it in your heads now… sorry about that.

    Can you feel it? If you have come to therapy here or with a PRI trained therapist this is one question that I am sure your therapist has asked many, many times. Probably to the point that you hear your therapist ask it every time you do your exercises at home. When we are doing an activity with our patients we are trying to turn specific muscles on and turn other specific muscles off to improve the way in which we move. If you cannot feel the specific muscles we want you to feel when doing your activities, or are feeling other muscles too much, you are not going to have the success with the activities that we would like you to have. So we ask: Can you feel this?… Can you feel that?… Are you feeling this?… Can you feel the love, tonight? (Just kidding). To underscore this importance of “can you feel it,“ over the next few blogs I want to highlight a few of the major muscles we want you to feel, and probably more importantly if you are not feeling them what we may need to work on to be able to feel the correct muscle work.
    Usually one of the first muscles we want our patients to feel is the left inner thigh muscle, or adductor. In our normal pattern of asymmetry our body has a tendency to center our weight, or base of support, over our right leg. This weight shift is usually accomplished with activity of the right inner thigh muscle to pull the body to the right. In order to do this our brain, primarily with reflex activity, turns off the left inner thigh muscle to make this shift easier. This in and of itself is not a bad thing as long as we have the ability to turn on our left inner thigh, turn off our right inner thigh and shift our weight to the left side as easily as we can to the right. Think about slow dancing (I’m thinking of a certain Elton John song…) and you can picture how the inner thigh muscles can pull or sway you from side to side. In order to get this side to side (frontal plane) activity to occur equally we want our patients to feel their left inner thigh work more than their right inner thigh to overcome our normal asymmetrical tendencies.
    So, can you feel it? If you can, Great! Keep feeling it because we want you to use that muscle to stabilize your pelvis and not let it sneak back to the right. If you can’t then we need to address some other issues so that you can feel it. The things that might keep someone from feeling their left inner thigh work are primarily things that prevent them from being able to get in a proper position that allows them to fully shift their center of gravity to their left side and shift their pelvis over the top of their left hip bone (known as AFIR to PRI trained PTs). There may be some restrictions in the hip joint itself (posterior capsule) that need to be stretched out to allow the normal joint mechanics to occur, and allow the pelvis to shift over the thigh bone. If someone cannot fully get their hip socket into that position it will be challenging at best to feel that inner thigh muscle work. This will probably be the first thing we will address with some stretching activities for your left hip. If the right inner thigh muscle is too strong, hyper active, or tight, it may be preventing the pelvis from shifting correctly to the left or the left inner thigh muscle from turning on. If this is the case we may need to do some activities to inhibit or shut off that hyperactive right inner thigh (right adductor inhibition). Sometimes our patients can feel their inner thigh great lying down, but then when we transition to standing activity all of a sudden it is impossible to feel it. We then usually cue those people to find and feel their right shoe arch. This is done for a few reasons. If the center of gravity is too far to the right (which is part of our normal asymmetrical pattern) the tendency is to roll onto the outer aspect of the right foot which will cause you to use your right inner thigh (as opposed to the left leg) more for stability. Again if the right inner thigh is working too much it will be difficult to find and feel the left inner thigh. If we cue a push into that right arch that will allow the center of gravity to shift back to the left, shut off the right inner thigh muscle and allow better feel of the left inner thigh. Sometimes we may need even to look into footwear or orthotics to assist this to happen. One last thing that may be affecting someone’s ability to shift their weight to the left appropriately is the inability to fill up the right lateral chest wall with air. Once again our normal asymmetrical bodies and patterns create difficulties for our left diaphragm to work efficiently and for our right lateral chest wall to open up or expand the way it should (right apical expansion). If this is significantly restricted it can limit the ability to shift to the left and to feel the left inner thigh. So we may need to even look into activities that stretch the right lateral (and sometimes posterior) chest wall to get the body in a position to allow the left inner thigh to work as well as we need it.
    I guess the bottom line is that if you cannot feel your left inner thigh and we keep asking and asking “Can you feel the love tonight?” let us know so we can address all of the issues that may be holding you back from progressing the way we want you to. Oh, and if you get the chance to see The Lion King I highly recommend it, and maybe, just maybe, you’ll hear your therapist’s voice saying “Can you feel it?”

  • Right turn only? Torin’s Pumpkin Patch adventures cause him to reflect on our “right turn world”...

    A few weekends ago on a beautiful Saturday morning we took our 3 young boys to a pumpkin patch just south of Lincoln and had a great time. I will say Nebraska definitely knows how to do pumpkin patches. There were jumping castles and giant inflatable pillows to hop on, trike rides for the kids, spooky houses, games, and of course hayrack rides to pick out pumpkins. One of the games that was there was a maze made of a brick pathway in which you had to get from the start to the finish only taking right turns. It turned out to be tricky and the solution required about 15 turns in circles to get to the finish (kind of like driving downtown on one way streets trying to find a parking space on a Saturday afternoon). Our kindergartener, not reading the directions, saw the start and finish and said “This is easy!” and with 2 left turns made it through the maze. Life was much easier when we could go left. Most of us in a way are trying to negotiate life only being able to make right turns. Not literally of course but we are all constantly fighting the tendency to shift and move to the right more than the left. As you all know one of the main tenets of our theory and treatment centers on the belief that we are all asymmetrical and right side dominant creatures. We prefer and feel more comfortable standing on our right leg, reaching with our right arm, looking with our right eye, etc. We feel this creates imbalance within our body that can lead to dysfunction and pain. Our treatment focus will often then focus on ways to encourage your body to move and shift to the left.
    This week in our staff meeting we discussed 4 things, that we call reference centers, which can help us to move our bodies to the left, or if not present can prevent you from moving to the left. The first is your left inner thigh muscle. That is often one of the first muscles we want our patients to feel as it can pull our pelvis or center of gravity to the left. There are of course specific things to make sure this happens in a correct manner but in general we want our patients to feel their left inner thigh. The second thing we discussed was the ability to feel your right arch when you walk. If you have a tendency to walk on the outside of your right foot you will never properly push yourself to the left side when you walk. We want you to be able to evert (foot turned out with little toes up) your right foot, and feel your right arch to propel your body to the left side when you walk. This can be done with proper shoes (see other posts in regards to proper shoe wear), orthotics, or other activities to encourage that motion. The third thing that can push you to the left is by looking with your eyes to the right. Our bodies subtly move the opposite direction our eyes are looking. In order to properly get our bodies to the left we need to be able to look to the right. Once on our left side, however we need to be able to then look to the left and have the ability to stay on our left side and not move back to the right. So if you have been asked to do some eye activities with your exercise program do not forget eye motion to the right as a way to assist you to get to your left side. The fourth reference center that we discussed today was your right wrist. If someone is very strongly pulled or oriented to the right side we will see the tendency to flex their right wrist or fist the right hand as if they were using a bar or something to literally pull their bodies to the right. The ability to relax and extend your right wrist with gait and during your exercises will assist you in getting to the left, or conversely if you do not relax your right wrist you will be more challenged in your ability to shift left. These are 4 things that as therapists and patients we can use or check to make sure our abilities to overcome our right dominance is maximized. Hopefully this information is helpful for you all and may even help us negotiate our life of mazes by being able to make left turns and right turns whenever we want. Unfortunately however it cannot help with parking downtown with all those one way streets.

  • Today's Challenge - How do you stand?

  • Torin Berge answers the question: What makes us different?

    I have now been here working at the Hruska Clinic for 1 month and am starting to get acclimated with Lincoln and the new job. We have explored the parks and pools with our kids, enjoyed the nice weather (heck, we are used to taking advantage of any nice day where we came from) and are starting to get our home comfortable and lived in. The question I have gotten the most from people since we moved is why did you move here? Just for a job? Why would you move your family to Lincoln, NE to work at the Hruska Clinic when you were so established where you were? Other than to try and get away from the North Dakota winters (yes I am actually looking forward to experiencing a Lincoln winter) the answer lies in what makes the Hruska Clinic different from any other clinic. As “the new guy” I feel I have a unique perspective on what makes this clinicdifferent. As I wrote before I spent the last 9 years working for a “traditional” physical therapy clinic in Minot, ND. I was blessed to have worked with some wonderful physical therapists and people. But I knew there was more out there. As a whole I feel physical therapists are caring professionals who truly want to help people feel and function better. Here at the Hruska Clinic we are not different in that respect at all. Everyone here is 1000% motivated to help people feel and function better. However, we have different, and I feel better, tools to get that job done. We utilize the science of Postural Restoration, developed and taught through the Postural Restoration Institute ™ to guide our treatment in order to address the cause of pain and dysfunction rather than trying to mask the symptoms of pain and dysfunction. The staff here is immersed in the science of Postural Restoration and dedicated to not only treating patients but taking it a step beyond that and getting our patients back to whatever their hopes and dreams may be. The first question we ask on our intake paperwork is what activities are you happiest doing, not what hurts. That frame of mind is what guides us. Those activities that make our patients happy become our goals as much as they are our patient’s goals. In addition to the people here, we have additional tools at our disposal to look beyond PT to address other needs that our patients may have. There are other influential factors that may be limiting what we can do as physical therapists that cannot be addressed anywhere other than at this clinic due to the resources we have available. For example, our patients may have needs for other specialties including dentists, optometrists, podiatrists, or other specialties that we recognize, understand, and can integrate with our treatments to allow us to achieve the amazing results that we see for people who have not had success anywhere else. This is what makes us different. Our attitude, our approach and our tools. They really are unmatched and not available anywhere else and that is why I moved here… oh and for the winters too… believe it or not.

  • Today's Challenge: How to get out of a chair...

  • How is Your Foundation Doing? Torin Berge, our new PT, writes his first Blog…

    As the “new guy” here at the Hruska Clinic I am not used to this blogging thing but hope to get accustomed to it. As you may or may not know I recently started here at the Hruska Clinic after working for the last 9 years for a hospital based clinic in Minot, ND which is my wife’s home town. The last month or 6 weeks has pretty much consisted of preparing and packing to move, moving, and unpacking once we got here. My family and I are enjoying the new experiences, and heat, that Lincoln has to offer. If you follow the news much you may have heard of the devastating flooding that hit our old town of Minot over the last month or two. This devastation only made our move more stressful as we left family and friends behind in the midst of the worst natural disaster that the area has ever dealt with. 12,000 of the almost 40,000 residents of the city were evacuated due to the flooding. 4100 homes had some water in them with upwards of 3000 having at least 5 feet on the main floor and several hundred with water above the roof line.
    This weekend as we continued to do all those little projects that come with moving into a new house, like staining a deck and building a swing-set for our boys, we were able to see some pictures, via Facebook, of the devastation in Minot as the water has now receded enough to let the residents back into their neighborhoods and assess their homes. After being under water for nearly 3 weeks the amount of damage done is truly devastating and the pictures I know do not do it justice. Many homes including my mother and father-in-laws house were either moved off of their foundation or had the foundation cave in. These houses are now unsafe for living in and most likely will need to be demolished and destroyed. The power of water and mother-nature is truly amazing.
    As I looked at pictures of these homes off their foundations, tilted, twisted, and caving in, and felt for the owners of them knowing that they may never be able to be restored, the PT in me could not keep from thinking about how our bodies are fighting that same stress all the time. We utilize the analogy of our pelvis being the foundation for our spine a lot here. We all put repetitive, asymmetrical, stress and strain on our pelvis with the asymmetrical demands of life and our tendencies to stand more on our right leg and reach more with our right arm, twisting our spine more to the left than to the right. This is caving in the foundation for the rest of our body. Our house, aka our thorax, is tilting, twisting and caving in just like those houses that need to be demolished in Minot. We therefore cannot breathe well. Our arms, like the decks on those houses than now sit at 45 degree angles from the ground, cannot work the way they should. Our necks and heads, like the chimneys on those houses, are tilted and starting to fall over.
    What a dire picture I paint. The good news is that unlike those houses that will probably be destroyed, we can restore our foundations and untwist our houses. With the power of a left hamstring, a left adductor and a properly opposed left diaphragm we can rebuild our houses and straighten out chimneys and decks and make our houses happy and livable again. It’s also a lot less messy. Please keep the residents of Minot and other flooded areas in your thoughts and if you need help with your foundation e-mail me or contact us here at the Hruska Clinic.