The Hruska Clinic Integrator
Stacy Masek on 02/17/2020
Lori discusses Pelvic Floor dysfunction (Video 1)
Posted on 02/13/2020
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.
Posted on 01/22/2020
Lori gives an update on the updates and upgrades to our 2020 shoe list. We hope the changes help you identify the importance of proper footwear and give you better tools to pick a better shoe.
Posted on 01/21/2020
Dave Drummer takes impressions for custom PRI foot orthotics manufactured by Dr Paul Coffin. The Hruska Clinic strives to meet all needs of our patients to help them address why they have the issues they do. This is one more example of how we will address all needs you have to give you the bast care we can.
Posted on 12/03/2019
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.
Posted on 06/12/2019
Read about Jason's upcoming talk at this years NATA Convention
Posted on 05/28/2019
As Jason prepares for another talk he will be giving soon he is revisiting some basics on pelvis and rib-cage position. As he prepares, this blog came back to mind for him so we'e like to repost it for you to revisit as well. If you'd like a pdf version of this article let us know.
Posted on 02/22/2019
After much deliberation the new 2019 Hruska Clinic shoe list is available. For a copy of the list and to watch a video from Lori about the list go to the Shoe list page from our homepage, or click here.
Posted on 01/22/2019
Read how socks, shoes, and squats helped Torin remember to not forget about the basics.
Jason Masek's Presentation From The 2018 NSCA Coaches Conference Is Now Online: Push, Pull, and Propulsion – The 10-20-30-40 ConceptPosted on 12/06/2018
Earlier this year Jason presented at the National Strength and Conditioning Association (NSCA) Coaches Conference. The presentation is now available online.
- Posted on 08/16/2018
- Posted on 03/20/2018
Posted on 02/14/2018
45 years of experience with dental integration finally came together for Ron. Read about our experience here.
Posted on 01/30/2018
Earlier this January we were blessed to host 2 gentlemen from Japan; Koichi YAMADA and Akira YOSHIMOTO; who came to Lincoln to see how our staff utilizes the science of Postural Restoration(R) in a clinical setting. They spent a day mentoring with us in the clinic as well as some time with the staff at PRI. Here is their testimonial in their best of English as well as some fun pictures from their time. Little do they know that we learned as much from them as we hope to have shared with them. We hope to continue to grow these types of relationships with passionate dedicated professionals wherever they are!
Posted on 01/12/2018
After giving out a bunch of balloons this week we felt revisiting this great video from Dave would be beneficial. Keep breathing!
- Posted on 11/28/2017
Posted on 11/06/2017
Check out this video of Lori describing what neutrality is and what it really means for your program. Neutrality is the starting line, not the finish line!
- Posted by on 04/04/2017
New PRIME Patient Care CoordinatorPosted on 01/31/2017
The Hruska Clinic is proud to be announcing the addition of Megan King to our staff as our dedicated PRIME Patient Care Coordinator. To learn more about Megan and our PRIME program click HERE.
Posted on 01/18/2017
Read an blog on our PRIME website from Torin outlining the difference between clarity and perspective and what that means for us as humans who want to move. I good general perspective on why we may have or struggle with issues that don't get better.
Posted on 11/03/2016
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.
Posted on 10/20/2016
We are pleased to have University of Rhode Island PT student Karl Busch here in the clinic doing a clinical internship. Here is a guest blog from him outlining something he's noticed in his first few weeks in the clinic. Here he talks about "Keeping Things Simple". Enjoy.
Posted on 10/10/2016
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.
Posted on 10/07/2016
Some things we've learned about Interdisciplinary Integration over the last 18 months since starting PRIME.
Posted on 10/06/2016
Here's a link to a video from Lori Thomsen, from her recent Interdisciplinary inservice on Patterns, Feet and Footwear showing the impact shoes can have on patterned movement.
Posted on 09/13/2016
Hear Lori talk about the difference between right and left hip flexors, their influences on and by breathing/diaphragm function and position, and how they can be treated differently once you understand this issue.
Posted on 09/08/2016
Listen to Lori discuss proper pelvis and rib cage position to safely and effectively perform planking-type activities.
Posted on 09/01/2016
Video blog from Lori Thomsen on the purpose and technique for PRI squatting, why we look at it and what it tells up about transitioning to loaded squatting as part of a strength program.
Posted on 08/31/2016
If you are considering or have been recommended to undergo any type of vision related treatment (strong glasses, vision therapy or training etc.) or have any concerns about your child's visual skills for reading or upright activity please read this great write up form Caiti (with assist to Dr. Heidi Wise) on what else may be playing a role and how our PTs may be able to assist.
Posted on 08/09/2016
Here are the links to all of our #MySoreSpot series blogs from the entire staff. Feel free to share with friends if they are complaining about their sore spots. We may be able to help explain #WhyItHurts.
Posted on 07/14/2016
"If they can help me, they can help anybody." -Megan
Here is the link to the final Meet Megan blog
Posted on 07/07/2016
Takuto Kondo and Kan Sugiyama traveled from Japan to take part in the Hruska Clinic's™ Clinical Integration Mentorship Program. Takuto discusses his experience at the Hruska Clinic™.
Posted on 07/05/2016
Here is the next part in our Meet Megan series. Hear Megan and Mike describe their experience and feelings after initiating treatment for Megan's dysautonomia/POTS.
Posted on 06/27/2016
Here is the second video in a series introducing you to a patient of the Hruska Clinic and PRIME. In this video hear from Megan's husband Mike as he describes what their life was like prior to coming to the clinic.
Posted on 06/23/2016
The last of our #MySoreSpot series looks at the very important left hamstring muscle. Dave does a great job explaining and demonstrating potentially #WhyYouHurt
Posted on 06/21/2016
Click here to Meet Megan who is a patient of the Hruska Clinic and PRIME program and learn about her background and history dealing with POTS and who she was prior to coming to the Hruska Clinic. Stay tuned for more videos as we get to know more about Megan and her recovery.
Posted on 05/31/2016
Jason discusses how the hip is often the overlooked source of knee pain.
Posted on 05/25/2016
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).
Posted on 05/16/2016
Caiti describes #WhyYouHurt in your lower back as many of our runners do. This is #MySoreSpot number 2 of our top 5.
Posted on 05/16/2016
See and hear Lori's patient describe what happens when Postural Restoration Institute® (PRI) techniques are applied to help her "feel the floor."
Posted on 05/12/2016
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.
Posted on 05/06/2016
Here is a video blog from Lori describing #WhyYouHurt if you have right piriformis (posterior hip) pain that may or may not have sciatic nerve implications when you run. This was one of the top 5 common sore spots as reported at the Lincoln Marathon Expo. ENjoy
Posted on 05/04/2016
Lori Thomsen describes the biomechanics behind the common human pattern we see that helps us determine #WhyYouHurt. Watch for upcoming blogs that will outline specifics how this pattern can cause specific areas of pain and describe the top 5 sore spots as reported by Lincoln Marathon runners at the 2016 expo.
#MySoreSpotPosted on 04/27/2016
Look for our staff at the Lincoln Marathon Expo, or follow us on social media (Facebook, Twitter and Instagram) this weekend as our staff will be there getting people to tell us about their sore spots. There will be fun surprises and opportunities for you to engage with us (potentially win a prize) and have a little fun before the big race on Sunday! Hope to see you there!
Posted on 04/21/2016
Caiti gives a great summary of what we are learning and doing here at the Hruska Clinic(TM) after taking a few days off last week for the Postural Restoration Institute®'s annual Interdisciplinary Symposium.
Posted on 04/12/2016
Caiti provides a brief explanation on assistive device functionality.
Posted by on 04/12/2016
持ってる 君は これまで されて 圧倒 "Have you ever been overwhelmed" Think of the first time you were ever exposed to Postural Restoration® whether you were a patient or a clinician you may have been overwhelmed by the visit, terminology, or even what you felt or saw. From a clinician's standpoint the language used is sometimes hard to follow. Now imagine what Yusuke felt like when he was trying to learn the Postural Restoration Institute® (PRI) language/concepts yet in another language (English). This goes to show you Postural Restoration® is becoming more of a universal language across the world and yes they have similar patients in Japan with the same patterns we have here in the United States. This blog discusses Yusuke Namba's observation time here at the Hruska Clinic(TM) (English Version).
Posted on 03/31/2016
Straight out of the Hruska Clinic(TM), Jason Masek's third article will be published in the Co-Kinetic (formerly known as SportEX) April 2016 issue, as well as online at https://co-kinetic.com/#_l_5w. Here is a preview!!
Posted on 03/28/2016
Yusuke Namba spent some time in the Hruska Clinic over the last several months and discusses his experience while at the clinic.
Posted on 03/02/2016
Jason demonstrates how activating a left ischiocondylar adductor and left abdominal wall eliminates right rib and intercostal wall pain. Check out his latest video blog.
Posted on 02/26/2016
Dave shows a unqiue way to improve balloon blowing technique for those people who struggle to find the power to get air into the balloon. This technique, that originated at the Hruska Clinic(TM), is taught as a core exercise through the Postural Restoration Institute® (www.posturalrestoration.com) and has been adapted and utilized to assist in treating anyone from the geriatric population to college athletics and professional sports teams.
Posted on 02/23/2016
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.
- Posted on 02/18/2016
- Posted on 02/16/2016
Posted on 02/04/2016
Hear from our newest PT, Caiti Daubman, as she introduces the influence of oral-motor activities on breathing, and cervico-cranio-mandibular management.
Posted on 01/26/2016
Click here to access the newly updated 2016 shoe list and a video blog from Lori outlining the most recent changes and updates to the list.
Posted on 01/20/2016
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.
- Posted on 01/14/2016
- Posted on 12/10/2015
Posted on 12/07/2015
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.
- Posted on 12/01/2015
Posted on 11/10/2015
Torin talks about the capital of Hungary, mnemonics, and what to do if your program is not working.
Posted on 09/24/2015
This video demonstrates the ability to sense the floor allowing an individual to move more fluidly. This individual's current footwear does not allow her to "sense" her entire foot on the floor, therefore her movement is impaired
Posted on 08/26/2015
Learn about what the Hruska Clinic PTs think about Multidisciplinary Integration.
- Posted on 08/04/2015
- Posted on 07/22/2015
- Posted on 07/06/2015
- Posted on 06/23/2015
- Posted on 06/22/2015
- Posted on 05/13/2015
- Posted on 05/13/2015
Torin Berge talks about "Managing the Occipital-Atlas (OA) Region: An introduction to management of POTS, Chiari, and other dysautonomic issues."Posted on 04/30/2015
- Posted on 04/15/2015
Posted on 04/02/2015
Lori Thomsen from the Hruska Clinic in Lincoln, NE discusses a case study with an anterior open-bite.
- Posted on 03/23/2015
Hruska Clinic's Jason Masek speaks on "Positional Influences, Breathing, and Performance: The Utilization of Postural Restoration for the Strength & Conditioning Specialist" at the 2015 NSCA Coaches Conference in Louisville, Kentucky.Posted on 03/23/2015
Hruska Clinic's Jason Masek speaks on "Positional Influences, Breathing, and Performance: The Utilization of Postural Restoration for the Strength & Conditioning Specialist" at the 2015 NSCA Coaches Conference in Louisville, Kentucky.
- Posted on 03/11/2015
- Posted on 03/11/2015
- Posted on 03/10/2015
- Posted on 03/06/2015
Posted on 03/05/2015
The most up-to-date recommended shoe list provided by the Hruska Clinic. Click on the title to check it out!
- Posted on 03/05/2015
- Posted by on 03/02/2015
Physical Therapy Student from Columbia University, Kasha Stevenson, discusses what she has seen at the Hruska ClinicPosted by on 03/02/2015
Hi, my name is Kasha, I am from Vermont and am a physical therapy student at Columbia University doing a 9 week internship at the Hruska Clinic.
“I’ve been everywhere and tried everything. Nothing took my pain away until I started coming to the Hruska Clinic.” This is the most frequent comment I hear from patients as they arrive from all over the United States (and sometimes abroad!) with different complaints and stories that usually started years ago.
Hour appointments allow a full history to be taken of the life the patient has lived and questions are asked that sometimes may seem obscure. Yes, it is important to know that you played the saxophone for 12 years or that no matter what shoe you wear you always get a blister on the outside of the right big toe. All of these details allow the experienced physical therapists here to understand the positions that your body feels comfortable. These small details are critical.
I am short of breath throughout the day or my legs want to keep going but I feel like I can’t get air in. This is something else I constantly hear at the Hruska Clinic. Breathing correctly is crucial. All sorts of pain and chronic problems stem from poor breathing. You may feel short of breath throughout the day, but most people do not know they struggle to breathe because the body naturally and efficiently compensates. Different postural positions and manual work can help to diagnose inadequate breathing and patients are amazed at how hard it is to breathe in some positions. And yes, there are a lot of balloons blown up here!
Integration and engagement. This is something people talk about, and here at the Hruska clinic it is put into action with each case. Patients are engaged throughout their treatment and expected to take responsibility. In some instances their care is integrated with the dentist, podiatrist, or optometrist on staff. Why would you need to see a dentist or podiatrist or optometrist for shoulder pain? Neurologically sometimes other systems are playing a role and need to be addressed. For example, sometimes when a patient cannot close their mouth and feel all their teeth back and front, both left and right this can cause instability in the mouth and impingement or pain elsewhere because the patient’s body needs stability. Also, if a patient sees too clear or isn’t aware of their peripheral vision it can cause the eyes to be too focused and not allow the body to relax.
I had not experienced this kind of integration between these professions before coming to the Hruska Clinic. During my 7 weeks I have seen a lot of cases where this integration between professionals allowed a patient to be pain free for the first time in years.
- Posted by on 07/31/2014
Trevor Rappa talks about The Effects of Breathing on the Autonomic Nervous SystemPosted by on 07/08/2014
Every patient or clinician who is familiar with PRI knows how important breathing is when performing PRI exercises. The reason for this is the effects that breathing has on the Autonomic Nervous System (ANS). The ANS is what controls our heart rate, respiratory rate, perspiration, digestion, and the other functions of our body that we do not think about on a moment to moment basis. The ANS has two divisions, sympathetic and parasympathetic. The sympathetic division is what works when we are anxious, scared, angry or anything else that gives us a big rush of adrenaline, it is the “fight or flight” response. When you are in a sympathetic state your breathing becomes shallow and rapid while your posture becomes more upright, or extended, which means your muscles have increased tone. You are stuck in the inhalation phase of breathing. The parasympathetic division is what is working after you eat a big meal and get sleepy, hence why it is often referred to as the “rest and digest” response. When you are parasympathetic your breathing slows down and your muscles relax which allows you to achieve a position of flexion. You are in the exhalation phase of breathing. The ability to get between these two states is called neutrality. The tests a PRI practitioner performs lets us know if you are neutral. If you have increased sympathetic tone then your joints will be in a poor position and not be able to move certain ways, for example your hip may not be able to fully adduct. This test result shows us that you are not neutral. Essentially, with these tests we are evaluating the state of your ANS.
The ANS is the reason why sometimes PRI practitioners ask questions that may seem unrelated to what you have come in for. You may come in because you have knee pain when you run but then get asked questions about if you get headaches regularly, have stomach pain, or wake up multiple times during the night. This is because studies have shown that people with chronic headaches 1 , stomach pain 2 , and sleep apnea 3 ,4 have increased sympathetic tone. The answers to these questions help us know if you have a problem regulating your ANS, or getting neutral. If you are stuck in a sympathetic state before you run, during your run, and after you run then you are putting extra stress on certain areas of your body, which in this example may be your knee. By helping you slow down your breathing, such as with a balloon in a 90/90 position5, we can help you get into a parasympathetic state. This will put your muscles and joints into a better position to function which often relieves the stress that may have been causing those areas to hurt. If this worked, then our tests would show that you are neutral which in the example before means that your leg would now be able to adduct. This is why we focus on breathing with every patient that we treat.
1. Jason J. Gass, and Alan G. Glaros. “Autonomic Dysregulation in Headache Patients” Appl Psychophysiol Biofeedback 2013 Dec;38(4):257-63. doi: 10.1007/s10484-013-9231-8.
2. C. Botha, AD. Farmer, M. Nilsson, C. Brock, AD. Gavrila, AM. Drewes, CH. Knowles, Q. Aziz. “Preliminary report: modulation of parasympathetic nervous system tone influences oesophageal pain hypersensitivity.” Gut 014 May 28. pii: gutjnl-2013-306698. doi: 10.1136/gutjnl-2013-306698.
3. Monaco, Annalisa, Ruggero Cattaneo, Luca Mesin, Edoardo Fiorucci, and Davide Pietropaoli. “Evaluation of Autonomic Nervous System in Sleep Apnea Patients Using Pupillometry under Occlusal Stress: A Pilot Study.” Cranio®(2014): 0886963413Z.000. Web.
4. F. Abboud, and R. Kumar.“Obstructive sleep apnea and insight into mechanisms of sympathetic overactivity.” J Clin Invest 2014 Apr 1;124(4):1454-7.
5. Boyle K, Olinick J, Lewis C. The Value of Blowing Up a Balloon. N Am J Sports Phys Ther. 2010;5(3):179–188.
Torin Berge Discusses how to keep on path with Postural RestorationPosted by on 07/08/2014
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.
- Posted by on 06/23/2014
Trevor Rappa from Columbia University at the Hruska ClinicPosted by on 06/12/2014
My name is Trevor Rappa and I am a PT student from Columbia University in New York City. Before going to PT school I attended Amherst College where I was a member of the football team. Playing football gave me a love for strength and conditioning which I pursued during an internship at Mike Boyle Strength and Conditioning. I was first introduced to PRI by my close friend and classmate Greg Spatz. Since taking my first PRI course with Ron Hruska in October 2013 I knew that I needed to learn more. This brought me here to the Hruska Clinic where I am fortunate to be doing a ten week clinical rotation. During this time I hope to share some of my experiences, thoughts, and lessons learned through this blog.
I hope you enjoy!
Trevor Rappa talks about NeutralityPosted by on 06/12/2014
Neutrality and Human Performance
My mentor Lori Thomsen has emphasized neutrality during my first two weeks at the Hruska Clinic. This weekend I took PRI Integration for the Home with James Anderson and learned about Human Performance. I hope to share my understanding of how these two concepts are related.
Tasks along a spectrum require the same foundational components. Rolling in bed and hitting a baseball require the ability to rotate your trunk. Standing up from a chair and dunking a basketball require force production from your hip extensors. All of these are on the same spectrum of human performance but at opposite ends. As James said during the course, an 18 year old and an 80 year old are both athletes, but one doesn’t move as fast as the other. Neutrality is the foundation that human performance should be built upon.
Neutrality is variability, a concept I was introduced to by Bill Hartman and Eric Oetter. This variability is seen in movement and in autonomic states. Neutrality is the ability to move in three planes, alternate and reciprocate, and demonstrate symmetrical movement patterns although we as humans are not symmetrical! This puts muscles and joints in the best position to potentially express speed, strength, quickness, or any other physical attribute.
Tri-planar performance is something all athletes should be able to do regardless of age. This is achieved by inhibiting our motor dominant left hemisphere which drives us into a right lateralized pattern (L AIC) to allow ourselves to become left lateralized (R AIC). Being neutral means that you are able to move back and forth between these lateralized patterns (perform gait) which indicates movement between the hemispheres of our brain. With excessive lateralization comes reduced variability.
Autonomic variability is transitioning between sympathetic and parasympathetic states. It allows one to be “on”, or sympathetic, during times of stress such as during a game and “off”, or parasympathetic, when there are no stressors and rest/recovery is needed. Being “on” is necessary at times to respond to certain stimuli, such as reacting when you lose your balance so you don’t fall or performing a max effort lift. It is good to become sympathetic when necessary, the problem comes when you cannot turn it off. A period of rest and recovery is necessary to integrate a stimulus that requires a high recruitment of energy sources into the system. This will allow one to handle the stimulus even better the next time they encounter it.
Neutrality is not a single point on a scale but it is a state that can change. After the course Zac Cupples, Conor Nordengren, and myself spoke with James on this idea of neutrality and human performance. To end this post I would like to share what the four of us came up with during our talk which I think ties this post together. “Achieving neutrality by minimizing lateralization and establishing autonomic variability.” This expands human performance.
David Drummer talks about flexibilityPosted by on 06/03/2014
Can a person be too flexible? I think most would argue the more flexible the better, but I have to disagree. I can’t tell you the number of patients I’ve worked with that I’ve told to stop stretching. And I always love the response I get of utter disbelief. Many will say something to the effect of “But I stretch everyday so I can place my palms on the floor”, yet they often have been fighting chronic pain for years with no idea why. After all, they’re active, otherwise healthy, and they stretch everyday.
Have you ever been on a walking bridge with a lot of other people? If so, you’ve probably felt the bridge give or drop beneath your feet. That is by design. If the bridge doesn’t give with the varying frequencies of all those feet pounding on it, the bridge could collapse. Being too rigid could be devastating to the structure. On the other hand, there needs to be some rigidity or structure to the bridge, or again the bridge could collapse. Neither scenario is good.
It’s the same with our bodies. Being too rigid, or lacking flexibility can lead to problems. Maybe you can’t reach down to put on your shoes and socks, or you can’t turn to see behind you when changing lanes in your car. But if you’re too flexible and you don’t have stability you may have back pain every time you lean over to pick something up or work in your garden. The list of problems that develop from too much or too little flexibility too long to cover in a short blog, but I hope you better understand why sometimes when you come to the Hruska Clinic you may be told to stop stretching.
If you have any thoughts or questions regarding my thoughts on flexibility, please feel free to contact me personally.
Hruska Clinic Clinical Integration Mentorship ProgramPosted by on 06/03/2014
Often times we get requests from local, national, and international physical therapists, athletic trainers, and other healthcare professionals wanting to spend a day at the Hruska Clinic™. We have recently developed a program to allow these indviduals the opportunity to shadow the Physical Therapists from the Hruska Clinic™ during their day-to-day interactions with their patients as well as integrating with other healthcare professionals. Completing a clinical integration mentorship program can provide the Postural Restoration® practitioner the added confidence and experience in implementing Postural Restoration® concepts and techniques. Check out the Hruska Clinic Clinical Integration Mentorship Program!
Washington Mystics' Head Athletic Trainer Visits the Hruska ClinicPosted by on 05/28/2014
You’re going to Nebraska again? What’s in Nebraska? These are the questions I was asked by my players, friends and family. Yes, I was visiting Lincoln, Nebraska for the third time in four months. After taking all three home study courses and five different live seminars from PRI, I was still missing something. I was not connecting the dots between what I had learned and what I needed to do, so I decided to spend a week at the Hruska Clinic to observe the treatment approach put into practice. The trip was exactly what I was looking for; it was amazing!
Going to the Hruska Clinic every day and seeing Ron, Lori, Torin, Dave and Jason actually treating and evaluating patients was fascinating. Observing them, and experiencing the PRI clinic staff go out of their way to explain what they were doing and why they chose specific treatments and exercies, was exactly what I needed. I had my “Ah-Ha!” moment when all the training clicked, and I became comfortable and confident with what I had learned. I finally knew what I need to do in PRI evaluations and treatments. The trip was invaluable for clarifying my studies and moving me from simply knowing to actually understanding.
My co-workers may say that I am drinking the PRI Kool-Aid, but after traveling the world and learning from the best osteopaths, chiro-practitioners and physical therapists, I am a firm believer that PRI should be the first technique used in treatment—similar to building a good foundation for a house. It is clear to me that without achieving neutrality, our subsequent treatments won’t be successful. I am so happy that I chose to take the final step of observing at the clinic.
Head Athletic Trainer
Head Strength and Conditioning Coach
You're Grounded!Posted by on 05/28/2014
You’re Grounded!! (But hopefully in a good way…)
“You’re Grounded!!” Luckily my kids are complete angels and I never have to say this at home… But at work I get to try and ground people all the time. Let me explain.
Recently the Postural Restoration InstituteTM hosted their annual Interdisciplinary Integration Course. This year the topic for the symposium explored the influence of gas (air) and gravity on our ability to control our bodies with movement and at rest. The symposium also described some common challenges that we experience in the clinic with people who struggle to deal effectively with gas and gravity. Some labels given to people who are challenged with their ability to manage gas and gravity include orthostatic intolerance (OI), dysautonomia, POTS (postural orthostatic tachycardia syndrome), chronic fatigue, scoliosis, and dizziness. In the clinic what we find with people with these challenges is an inability to appropriately perceive where they are in space due to a limited ability to appreciate sensory, physical, visual, or vestibular cues. We call these sensory cues reference centers. Our brain utilizes sensory input from many different areas including your feet, joints, muscles/tendons, eyes, auditory and vestibular portions of our ears to know where we are at in space, where we are at compared to everything else, and what we need to do to maintain that position or move. The brain is constantly receiving, filtering, processing and responding to those cues literally thousands or millions of times a second (see quote at the end of the blog). This takes place automatically of course through a system called our autonomic nervous system (ANS). When that information is skewed, missing, or unable to be processed effectively, our ability to hold our bodies up against gravity, move or regulate our bodies becomes challenged and symptoms ensue. These symptoms are usually then related to functions of the autonomic nervous system including dizziness, poor management of heart rate or blood pressure, digestive troubles, poor sleep regulation etc. Many more issues arise when this system designed to regulate the majority of our body’s functions becomes stressed. We may talk more specifically about these at a later date; however, the purpose of this blog is not to describe physiologically what is going on but to try to start to clinically give some ideas of what to do about it.
With this type of patient the main issue that needs to be addressed is giving these patients appropriate sensory reference centers or things to feel to allow their jacked up nervous system to relearn how to regulate itself. Any traditional activity, PRI based or not, that does not give these patients an appropriate, sensory, significant reference center is going to have limited success. There are a lot of things that we can think about to get good appropriate sensory input, but what I want to focus on now is feeling appropriate ground contact with your feet. We want our patients, especially those who are struggling with gravity to effectively and appropriately feel the floor underneath them. We want them to be grounded. As each foot hits the floor with walking or standing there should be input sent from your foot to the brain about where your body (center of gravity) is at in comparison to that foot, what direction, if any, the floor is tilting or moving, and many other sensory cues that the brain can use to feel secure, or insecure, about its position in space and how the body is moving. If those cues are absent, not perceived, or poor, the body loses a lot of information and security in its ability to maintain posture and move without jacking the autonomic nervous system up and going into a state of extension or fight/flight (AKA the bear in the room syndrome). If our patients do not feel a connection, or grounding, to the floor through each foot alternately they will not feel comfortable in their ability to walk, move, or hold themselves up against gravity, no matter what shoe, orthotic, lift score, breathing pattern, or pair of glasses they have on. A connection to the ground and floor limits the need for extension (back and neck) muscles to pull us up. Imagine a marionette puppet. You know the puppets with strings holding them up that you can use to make the puppet move, or walk (if you still don’t know google ‘N’sync no strings attached’). I tell my patients that they are a marionette puppet and if their feet are not connected to the ground when the walk the strings are pulling them up. The neck is usually the puppet master. Keeping them pulled up and away from the ground. If they can get connected back to the ground the puppet master’s strings (neck) can go on slack or relax.
In the clinic I will often ask my patients to stand and tell me how heavy they feel. I will say “if you weighed 100 pounds (the math is easier and then I don’t have to guess weights) how heavy do you feel, or how much of that weight is on the ground through your feet? People will often tell me they feel much lighter than 100 pounds, or they feel 20 pounds on their feet but 80 pounds on their back or neck. For those people the floor starts at the low back or neck and the puppet master is pulling them up. They are floating away, probably dizzy or unstable, not neutral, and preparing to fight or run from the bear in the room. If I can get them to feel 100 pounds on their feet and ground them to the floor the puppet master will no longer need to pull them up, they will be more secure, probably neutral, and more relaxed. One tool that I will use to show people is to make a belt out of 2- 3# ankle weights and strap it to their waist with one weight on each ilium. As they stand and shift and walk they should be able to feel the weight transferred down to their feet. As one foot is picked up the weight on that ilium will pull down and ground them to the other foot. As they alternately move and walk their brain will become more grounded and the puppet master (aka the neck) can relax. I will often check them out and they will be neutral. Have them stand up, take the weights off, and they can often feel themselves getting lighter and floating away. Now not neutral.
Now you could have them wear an ankle weight belt, and maybe that is the new up and coming fashion, but how are we going to get that carryover to the rest of their life. If we aren’t going to push their feet down into the floor we need to have the floor push up into their feet. This is what I want my patients to feel. Not just an awareness of the floor or an arch or a heel, but can they actually feel the floor under their foot come up as they shift their weight to that leg. With each step as you shift from side to side the floor (right or left) should come up into your foot as weight is loaded on to it. If not they are floating, not grounded and extending. If you can feel the floor as a stable base you can now shift, turn on a glute, and push yourself forward. Initially this needs to be a conscious thought, not with every step you take but with specific exercises. Let’s take a retro stair exercise that is done a lot for lots of reasons. We normally would cue our patients to step up with their left foot, shift their hip back and to the left to get their pant zipper over their toe, and weight to their heel while keeping their back rounded. This is absolutely correct to get into left AFIR and we can then push slowly and use glutes to step up. Not a bad deal, but were they grounded? I know we felt a heel but did the floor come up. I have started to really emphasize the step of this exercise where they shift back to their left side. I want my patients (whether they are grounded or not) to feel the step push up into their foot as the shift back to their left hip. The emphasis needs to be on the floor coming up, not the hip going back. If they don’t feel the floor come up I will have them shift the weight back on the right foot and try again. As soon as they feel the step pushing up into their foot as they shift back immediately they feel more grounded and connected. If done correctly they all say they feel more muscle activity in their quad, inner thigh and glute as they feel the floor push up. I will tell them to resist the floor coming up and try to feel as if they are pushing the step down as they bring the right foot up to the next step. If the thought is to step UP they will not stay grounded, if they are pushing the step DOWN they will stay grounded. Go try it. Feel the floor come up, push the floor away, feel the leg load up and work harder. I am getting more muscle awareness and work with this cuing than with any other cues I give. This is a cue you can give with any standing activity. A passive AFIR squat: feel the floor come up as you shift back. Step overs: Feel the floor come up as you load the leg, push the floor away as you step over, feel the floor come back up as you tap the foot down. Forward stairs (normal walking): feel the step come up into each foot as you go up the stairs, push the stairs down as you go up. Squats/lunges: Feel the floor come UP (not your body going down) as you squat or lunge and push the floor DOWN as you come up. The more that feeling of being grounded becomes natural (and desirable) the less the puppet master wins.
Bye Bye Bye… (one last N’sync reference for those paying attention)
Caitlin Daubman discusses her fifth week at the Hruska ClinicPosted by on 05/06/2014
Week 5: “Life is Short , smile while you still have teeth.”
This week was filled with patients visiting the Hruska Clinic from all over the United States. They traveled from as far as Massachusetts, Virginia, and Louisiana to stay the week in Lincoln in hopes of finding a solution to their complex health history and primary limitations due to pain. These patients were referred to us by the PT’s or ATC’s in their area for a second opinion or assistance with progressing their current program. Jason Masek’s experience in assessing and treating patients with cranial asymmetries as well as temporal-mandibular dysfunction was helpful for all of these patients. Each of these patients had a different primary complaint (hip pain, shin pain, headache, foot pain); and each of the patients had been through many different treatment approaches (injections, chiropractic, orthodontia, acupuncture, pharmaceuticals, or instructions to simply rest). However, none of these patients found lasting resolution of the pain.
Jason evaluated them and none of them were neutral. Repositioning exercises were completed and patients were still not neutral. Footwear was corrected and reevaluation showed the same L AIC or PEC patterns. Therefore, something else was holding them out of neutral and locking them into their pattern. Another interesting piece of information was that these patients either were presently in braces or had just finished orthodontia repositioning their bite. Jason discovered that the issues for these patients was stemming from their bite. These patients had limited or suboptimal occlusion between maxillary and mandibular teeth due to cranial torsions or an elevated palate. Jason took them out of their bite through the use of an oral splint, and reevaluation showed the patient finally achieved neutrality! It was amazing that simply removing the patient’s normal reference centers (their bite), the patient easily transitioned to neutral.
Treatment options for these patients included using oral splints during exercises to achieve neutrality and work the excessively weak and underutilized musculature that had been neglected for so long while being in L AIC or PEC patterns. The progress at the pelvis would be limited by the permanence of their TMJ/cranial positioning. Communication between physical therapist and orthodontist began and allowed for integration of a new plan of care for the patient. Treatment options included braces being removed or wires snipped temporarily, oral splints designed, and ALF’s were applied for palatal expansion in patients with symptomatic cranial torsions.
To some, this may seem like very intense or excessive measures to take for a future treatment plan. However, these patients have been through it all and the next step suggested to them by their healthcare professions have been more invasive or permanent treatments (nerve blocks, piriformis release, jaw surgery, teeth extraction, plantar fascia release). Conservative care is an investment, and one that pays off in the patient’s future to achieve a successful outcome utilizing and optimizing your body’s natural anatomy and function.
Caitlin Daubman discusses her fourth week at the Hruska ClinicPosted by on 04/17/2014
Week 4: “Never put off till tomorrow what you can do today.”
This well-known phrase can be dangerous as many people have internalized it as a way of life.
Like many of you, I know all too well the guilty feeling that accompanies being idle. However, I will aim to highlight the effects on our body when we operate like this, and methods to change it. We all have numerous stressors that bear heavy loads on us day to day. In order to deal with these, we feel compelled to keep up with the race. We operate in over-drive. There is a familiar feeling of fatigue- waking up from restless nights where sleep is interrupted by one’s own snoring, or jolting awake from halted breath, jaws sore from clenching, with panting breath and heart racing. You may be one of the many whose body demands a cup of coffee to get you through the morning hours before the ‘afternoon yawns’ set in. All throughout the day, your heels don’t touch the ground and you likely aren’t aware if you are even breathing - if you are, you can’t feel it.If you cannot identify with these as a reflection of your life, then thankfully YOU are doing something right! YOU are the person that the majority of society would like to resemble. As a PRC or PRT, you have probably heard these complaints from your patients/clients.
Last week I had the opportunity to sit in with Jason Masek and Ron Hruska as they saw some interesting patients. These patients were young females which Ron and Jason discovered to be orthostatic insufficient or dysautonomic. They presented with chief complaints of distal extremity pain but also mentioned headaches, dizziness, and fatigue. Their gait cycles were fast short strides lacking heel strike and trunk rotation. In essence these women felt and moved as if they were weightless. These women- like many other future patients out there- are operating in over-drive. Their ribs are elevated, they are over-inflated, and their ANS has adjusted to match this over-active system. Ron and Jason helped them find the ground using purposeful movements powering forward by pushing with the LE’s, and they taught them how to breathe. After the PRI exercise interventions to embrace gravity and use the diaphragm with chest expansion to breathe, the patients were neutral and reported feeling better overall and feeling grounded.
The Interdisciplinary Integration PRI © conference last week taught me a lot about this common issue in a growing patient population, and the methods to treat it. Using PRI techniques, we can play an important role in the management of symptoms that accompany orthostatic insufficiency and dysautonomia through: embracing gravity, exhalation, chest expansion, and the strength of the legs to power us on the journey!
Caitlin Daubman discusses her third week at the Hruska ClinicPosted by on 04/17/2014
Week 3: Versatility
The knowledge I have gained from the PRI Myokinematic Restoration course has been integrated to a deeper level this week. I have seen the therapists at Hruska Clinic prescribe PRI exercises to patients that are progressing to a high level and have greater ability to function with neutrality. A patient training for a marathon is able to run 8-9 miles before proximal hamstring pain sets in and then soreness persists afterward. Upon examination and testing, the patient was neutral and had sufficient hamstring and adduction strength. In my reasoning, the patient was neutral, had “hole control”, and was strong in most of the important areas. What could be the issue resulting in her pain onset only after so many miles?
The PT noticed that the area contributing to the patient’s problem was the glutes. We learn in Myokinematics about the important role of the external rotation fibers of the Right gluteus maximus and the extension fibers of the Left gluteus maximus, while also the Gluteus minimus and medius for stabilizing the left. The right glute max needs to be a stronger pusher to allow facilitate transitioning of the body over to the left stance during gait, in doing so, it acts to rotate the sacrum toward the left during right stance/push-off. The left glute max needs to act as hip extensor to propel the body forward rather than a heavy reliance on the left hamstring muscle group.
For treatment, it was really interesting seeing the Retro Stair activity to work BOTH areas! The versatility and benefits of this exercise to the whole body make it one of my favorites: increase left AFIR, stretch left posterior capsule, facilitate combination of Left adduction with gluteal activation, inhibiting the back extensors and hip flexors; allow transitioning from left to/from right and strengthening the right to be a ‘pushing’ side.
1. Left stair ascent: Shift into the left hip and focus on stability by lifting the right leg and holding the position before pushing up.
a. Working Left Glute Max Extension fibers, Left Glute Med and Min
2. Right stair ascent: Shift into the right hip and focus on strength by pushing into right AFER and left AFIR placing left foot on to the next step.
a. Working Right Glute Max ER fibers
Caitlin Daubman discusses her second week at the Hruska ClinicPosted by on 04/01/2014
Week 2 :
“If you don’t know it by now, you don’t know it.” - A phrase commonly delivered by those who are beyond the hurdles of graduate school, and also a phrase that I internalize so to promote my procrastination of studying. Rounding out my last year of PT school, the PT Boards are quickly approaching and I am knee deep in the most interesting clinical rotation here at Hruska Clinic. I have a genuine interest and motivation to learn PRI material and I am receiving many opportunities to do so every day. Simultaneously, I’m preparing and studying for the PT Boards from the knowledge base that has been built over three years. There are several points I noticed this week that are congruent between PRI and Board prep material, and some areas that diverge.
Here are examples of each:
1. Comparable: Pumps within the body that return blood back to the heart
a. PRI: I observed Ron Hruska treating a patient with dysautonomia, specifically diagnosed with POTs. I learned along with the patient
while he educated us on the areas of the body on which this patient needed to focus. Treatment methods for patients with dysautonomia and/or POTS are centered in:
- Finding and embracing gravity
- Strengthening the LE muscles to act as a pump for the body below the iliac crest
- Utilizing the diaphragm as a pump above the iliac crest.
b. Boards: I read these three points as they pertain to Venous circulation in the Cardiopulmonary section I studied that night. We know that these are the methods the body uses to return blood to the heart. However, I had been unaware of how to integrate this material into an examination and treatment plan for this patient population as Ron demonstrated.
2. Contrasting: Hip mechanics and range of motion testing
a. PRI: limited supine SLR unilaterally indicates an anteriorly tilted innominate. Hamstrings are elongated due to pelvis position pulling the attachment sites further apart; therefore it limits the available motion into hip flexion.
b. Boards: limited supine SLR unilaterally indicates a posteriorly tilted innominate. Hamstrings are short, strong, and tight, pulling the attachment sites closer together and limiting the available motion into hip flexion.
There are always opportunities for new learning, re-learning, or understanding concepts at a deeper level. What are some concepts/areas that you find particularly interesting and/or challenging between conventional PT and PRI?
DPT ’14, MHA ‘14
Posted by on 03/31/2014
Hruska Clinic physical therapist Lori Thomsen discusses a recent article in April’s issue of Running Times, titled “It’s all in the Hips.”
Caitlin Daubman Discusses her first Week at the Hruska ClinicPosted by on 03/26/2014
I have completed my first of eight weeks as an intern at Hruska Clinic. This is my last internship before graduating with my DPT in May. It feels like I have come ‘full-circle’ as they say. After seven years, I am back in my home town learning from the very people that inspired me to pursue the profession of physical therapy. The only things I knew about PRI was what I experienced first-hand as a patient roughly 10 years ago. As a freshman in high school, I became determined to be a physical therapist so that I could treat and help others the way Ron and the professionals at Hruska Clinic helped me. I wanted to practice truly individualized treatment plans, instead of the traditional therapy practice which is dominated by symptom management and protocols.
Day one at the clinic, Jason asked me what I knew about PRI. To say I knew ‘a little’ about PRI was an understatement. I understood the exercises I had been prescribed over the years and their purpose. However, to examine, evaluate, assess and plan a treatment from the perspective of the therapist was far beyond my understanding. My brain operates conventionally with the material that has been ingrained in my mind from three years of a rigorous PT curriculum. Presently, the Left AIC and PEC patterns are no longer foreign terminology to me as I am reading about them in Myokinematics and observing them in our patients daily. I understand the asymmetries and exercises that are given to the patients due to continued explanations from Jason and the other clinicians here. Right now, I am a sponge. My wheels are constantly spinning, critically thinking, mentally processing, and comparing what I knew to what I am seeing and learning here. I have a great deal more to learn and I am enjoying every opportunity to do so.
It is an unbelievable experience. Working with all of the clinicians and their patients has allowed me to see a great variety. I will continue to grow in my understanding and hopefully become more competent with PRI throughout the course of this internship.
Caitlin Daubman, SPT’14 MHA’14