Interview with Zac Cupples | Modern Manual Therapy Blog

Interview with Zac Cupples

I had the opportunity to meet Dr. Zac Cupples in person and have lunch with him at one of my Chicago area Eclectic Approach courses earlier this year. He was one of the online PTs that suggested I start taking some PRI courses.

Knowing his background in pain science and other systems, I decided to give it a shot and was happy with the courses. Zac reads a lot of texts, watches online seminars frequently, and takes a ton of con-ed. His blog, zaccupples.com is chock full of reviews, one of my favorite recently being DNS compared to PRI. He also recently helped me

I decided to interview him after his most recent PRI course, Advanced Integration, which he just completed this past weekend. The interview is below.

Tell us how you got interested in physical therapy

First off, thank you so much for giving me the opportunity for this interview Erson. I am to say the least humbled that you wish to hear this stuff from me.

I have always been interested in movement ever since I ran competitively, but PT was actually my backup choice. I originally was going to be a chiropractor, but then I worked for one and determined that route was not for me. 

I was still interested in movement and performance, and felt PT would be a good option. It wasn't until I observed aquatic therapy that I knew this was what I needed to do. I watched a patient who had a spinal cord injury enter the pool and move an amazing amount more than he ever could on land. I have had the drive for this profession ever since.

Who are your biggest influences as a clinician?

There are a lot of names I could throw out based on what I have read, but I only will list the people I have personally interacted with.

The most influential man for me on multiple levels has been my mentor Bill Hartman. Bill is one of the most brilliant people I have ever met, and observing and learning from him has shaped every facet of the way I approach patient care. I am forever indebted to him for that. That man is a wizard with the nervous system, and his continuous drive to get better is inspiring. There's a reason I keep going back to watch him work.

Next on the list is Adriaan Louw. I have had the pleasure of interacting with this man multiple times through my orthopedic residency, and he is the reason I hopped on the pain train. He completely changed the way I interact and educate my patients.   

My other guy in my big 3 is a guy who if you don't know now I guarantee you will in the future: Eric Oetter. He is currently a PT student, but easily one of the smartest people/clinicians I know. His ability to assimilate and apply information effortlessly is awe-inspiring, and I often go to him to better myself. He keeps me hungry to get better.

There are so many other people who I could list, and just need to give a shout out to Scott Passman, Zach Moore, Jae Chung, Mike Robertson, Lance Goyke, Connor Ryan, Young Matt, Doug Kechijian, Mike Roncarati, the folks at PRI, and the folks from my residency. The list goes on, but these people helped me be me.

What drives your need to learn as much as possible?

My patients drive me the most. What a lot of clinicians don't realize is that people are trusting you with their health. Trusting you with their bodies, and that you will guide them to getting better. If I cannot give them the best care possible, then I am doing them a disservice at best and hurting them at worst. And because I still fail quite a bit of patients I must keep learning so I fail them less. PT is a profession of self-sacrifice for the greater good...Kinda like Batman :)

Moreover, this stuff regarding our profession is just so damn interesting. How can you not want to learn this stuff? 

What is your favorite PT related text?

This may be the hardest question yet, as I have read so many good texts. I will give you 3 for 3 different reasons.

1) The Sensitive Nervous System - Gives the best explanation for how the nervous system works, especially regarding painful states.

2) On Intelligence - Explains how the cortex works, and gives a general framework for how every intervention we apply works.

3) The Definitive Book of Body Language - Helps you apply the above 2 in the most nonthreatening unconscious manner. Because if you can't get your patients to buy-in it's game over. 

You are very influenced by PRI among other things, what attracted you to their system of evaluation and treatment?

Bill was the one who kindly introduced me to this system when I was a student. And what was nice was even though we were crappy at it to start, we still got great results. 

After learning more about the nervous system, I became further engrossed with PRI. It is all neurology. They have basically found out how to measure the autonomic nervous system's status peripherally. And the fact that the testing helps guide your treatment, I struggle much less in determining where my interventions should go.

The best part? PRI allows you to put the success in the patients hands. The less they have to rely on me, the more they become empowered to get better. And that is probably the most important thing when recovering from pain.

What have they updated during the time between their home study courses Myokin and Postural Respiration and now?

Much of the content in terms of testing, peripheral theory, and intervention is similar. The biggest change I have noticed is that they are mentioning the nervous system way more as the foundation. In every course I have been to, we spend at least an hour discussing the brain as the primary driver. 

I have also noticed that they talk less about treating pain. They more treat position of the ANS which can have an indirect influence on pain. 

What is the order of courses you would recommend?

For the basic three, I would go myokinematic restoration, postural respiration, and pelvis restoration. These three alone will let you help a lot of people.

To really link the above three together, you will likely want to take Impingement and Instability, Craniocervical Mandibular Restoration, and Advanced integration in that order. Lastly finish with Vision if you really want your mind blown.

I have yet to take the cranial and visual course (planned next year), but know enough from my mentors to be dangerous, and survive AI.

Stay tuned on their new affiliate courses.

Any drawbacks to their system?

You will do well taking the basic courses, but really appreciating the entire system takes a lot of time, energy, and money. I feel I will have to take these courses multiple times to truly understand how to effectively apply what I am learning.

The exercises are also challenging to teach, as their are multiple parts to each of them; thus requiring a lot of hands-on coaching.

I will also say really being completely successful with the system will likely require the help of MDs, optometrists, dentists, podiatrists, orthotists/prosthetists, and audiologists. There will be many patients that you will be unable to get neutral with your skillset, and getting these providers on board will be a challenge. 

How do you incorporate a Pain Science Approach into PRI's system?

Seamlessly. The most common misconception about PRI is that it is all pathoanatomy and biomechanics. Far from the case. The postures in PRI are what we fall back on as a response to threat, whatever that threat may be. Positioning my body in right stance helps me maximize the central tendon of my larger right hemidiaphragm, which will make certain I keep respiration going, thus keeping me alive. Using this posture is not bad, wrong, or dysfunctional. It's normal. What's not normal is when I exclusively utilize this posture. It is as if you would constantly be responding to threat (sympathetically driven). So what we hope to achieve is being sympathetic (on) when you need to, and parasympathetic (off) when you need to.

Since we know the influence autonomics have on pain, we can see where PRI methodology fits in to a pain neuroscience framework. They are far from mutually exclusive.  

I hope to go a little more in-depth on this in a future post.

If you have restored "neutrality" but the patient has not reported any change in pain or function, what is your plan B?

Restoring neutrality is only step one to the process. Our goal is to be able to get the patient to reciprocally alternate between left and right stance with diaphragmatic integrity. So until this is achieved, you may not always have large pain effects (though often you will).

But that doesn't mean I won't do other stuff. Taking the defensive posture out of the mix is often the first step in the clinical process. From there I have to figure out to what extent the nervous system is involved. Here I utilize Butler classifications i.e. determining if nociceptive, peripheral neuropathic, or central mechanisms are more dominant. 

Once I determine this, I use various manual therapies and forms of graded exposure, with the ultimate goal to desensitize the nervous system and keep things as painless as possible. I have my favorite ways to achieve the above, but my selection of which will work best depends on the patient. 

But I will say that the better I get at PRI, the less manual therapy I have to perform. 

Any closing thoughts? 

Everyone must realize that we are all trying to manage the perception of threat with our patients, whatever that threat may be. The way we do this is by managing the inputs we can influence with out skillset, and there are multiple ways to do that. So let's get along internet :)

Thank you so much for the interview Erson. And get back to Chicagoland ASAP :)

For more information on PRI, including their excellent home study courses, visit their site posturalrestoration.com.

Keeping it Eclectic....

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