PRIME Case Study: Episode I: “A New Hope”

(Names have been changed to protect the innocent, and some details and background information have been omitted for the sake of time without sacrificing the main points we are trying to get across)

To continue the discussion from our last blog where we reflected on the power of integration with our PRIME program including a PRC therapist who referred a patient to see us I’d like to outline a case study to hopefully show how the process works in our PRIME program. I am not a Star Wars geek, but just couldn’t help form using the titles a little bit. Forgive me if things don’t live up to the originals…

“A long time ago in a galaxy (city) far, (but not too) far away…..”

“Chris” started seeing a local Postural Restoration Certified™ (PRC) therapist following years of chronic problems, including back and neck issues that had been managed off and on with various tools and varying successes. Unfortunately, over the last 12-18 months the symptoms had started worsening, with radicular symptoms down both arms and increased dizziness that went from intermittent to near constant. These symptoms unfortunately led to an inability to continue working. The PRC therapist worked with Chris for 9 months after identifying a patho-PEC pattern. After 9 months of Postural Restoration® manual and non-manual techniques to address this pattern, footwear recommendations, custom Postural Restoration® foot orthotics from Dr. Paul Coffin, and some sensory education, Chris still came into the clinic each session in a poor postural pattern. At each session Chris was always in a PEC (Posterior Exterior Chain as described by the Postural Restoration Institute® (PRI) or in general low back extension) pattern and even with the activities given by the therapist could never fully inhibit either side of her neck (PRI bilateral TMCC pattern) or her right thorax/chest wall (PRI right BC pattern). This PRC took a risk and because of their inability to show and maintain progress referred Chris to fill out the PRIME self-assessment form, as well as the PRIME triage form and faxed them to us along with eye records and pictures of Chris’ occlusion as outlined in our Triage paperwork.

Our PRIME team looked at all the information sent and decided that the following issues led us to see Chris as a patient with top-down issues perfect suited for integration with our PRIME program:

1. long standing history of issues in multiple areas;
2. an inability for a respected PRC therapist who despite using the tools available was unable to fully assist the patient getting (much less maintaining) neutral;
3. variable intensity of issues including the neck and back pain;
4. motion sickness;
5. poor reading comprehension, and
6. long standing visual dysfunction and dizziness.

The planned interventions for Chris included:
1. change in visual perception PRI Vision intervention, under the care of our PRI Vision team to reorient Chris in a “proper’ spatial relationship with the rest of the world;
2. an intra-oral appliance, made by out PRIME team dental staff, that would help with appropriate occlusal reference and stability once the visual system was addressed;
3. a consultation from Dr. Paul Coffin (the PRIME podiatrist) to see if any adjustments of the previously made orthotics would need to be made after seeing the other team members;
4. several sessions with a Hruska Clinic PT/PRIME case manager to teach home exercise program, progression and educate Chris on utilization and wearing of her new sensory orthotics and ensure neutrality was maintained with each.

Chris was scheduled to come to Lincoln, NE for a PRIME week where she would see PRI Vision, a Hruska Clinic PT, our dentist who took impressions for and calibrated her splint on site with the PT ensuring neutrality, and Dr. Coffin over a period of 4 days.

The week Chris was here in Lincoln, NE appointments were started in PRI Vision with Ron Hruska, PT and Dr. Heidi Wise, OD who identified in Chris a difficulty in processing multiple areas of sensory input including:
1. floor awareness;
2. visual-spatial (peripheral awareness);
3. possible auditory processing difficulties, and
4. vestibular hypersensitivity.

Chris was in a PEC pattern with a straight leg raise (SLR) of >100 degrees (indicating a lack of floor up awareness and use) despite continuing with a good PRI program as prescribed by the referring therapist. With a change in visual input through PRI Vision prescribed lenses the following changes were noted:
1. Chris was able to achieve a neutral position with SLR of 85 degrees bilaterally.
2. Chris demonstrated ability to center well on both legs and feel a sway when shifting from side to side that had never been felt before.
3. Chris could feel neck and back tension melt away with the PRI-Vision glasses on, and
4. Chris was able to feel the felt the floor transition from foot to foot with postural sway.

Impressions were taken by our PRIME dentist while in the new PRI vision glasses on the second day and neutrality was confirmed by the case managing physical therapist. The oral splint was seated and calibrated on the final day, again with neutrality confirmed by the physical therapist to ensure improved carryover.

Three sessions of physical therapy over three days was done with a Hruska Clinic PT to implement a program emphasizing the following issues:
1. start an upright sensory based PRI Vision program focusing on sensing floor-up stability and postural sway;
2. instruction in progression ideas and timeframes;
3. potential adjunct treatment considerations including when to progress exercises, and what things to be working toward including not only PRI Vision exercises but also traditional PRI progressions.

Dr. Paul Coffin saw Chris to adjust the current foot orthotics to allow better sense of arches for improved transition in the frontal plane. This matched the focus of the PT program for upright sensory minded postural sway.

As part of her discharge summary Chris was given written instruction on what the main issues are(sensory awareness and processing of floor and rhythmic shifting from side to side) as well as what to do for exercise, use of glasses, splint and orthotics, and what to do for progression and when to look at progressing. We also gave Chris things to look for to know when it might be time to return to PRIME for progression including if plateauing or stoppage of progress, inability to stay neutral with the current set of orthotics (glasses, splint and footwear) or gradual return of symptoms. This information was also forwarded to the referring PRC therapist. Initially some good feedback between Chris, the local therapist and the PRIME team was needed to ensure everyone was on the same page.

The end of PRIME week was not the end of our treatment with Chris. Episode 2 of the saga (“The Empire Strikes Back?”) would be the hard work and dedication of Chris, and the referring PT. As they progressed through the recommendations given progress was made, however a plateau was reached. With some good communication we were able to peel back the layers and eventually came to a point where a return to PRIME was needed. Check back with the next blog to see when Chris needed to come back and how we came to that decision and how continued engagement with the PRIME program should help us see further improvements.

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