Just recently attended another excellent PRI course taught by Lori Thomsen and new instructor Jesse Ham called Pelvis Restoration.
The weekend was filled with great discussion about inlets, outlets, shoes, and many other pearls that helped solidify my PRI understanding.
So without further ado, let’s summarize. If this is your first reading on a PRI course, it may be beneficial to review my post on Myokinematic Restoration.
Jesse started off the class discussing some PRI basic philosophical tenets.
In PRI, we talk a great deal about position, which will be defined as a stance or posture at one point in time. Or as Jesse defined it, a position one can maintain for an extended period of time without pain.
With this operational definition, our goal as a PRI clinician or trainer is to organize activities in the following order:
- Reposition – inhibit muscle chains.
- Retrain – Facilitate muscle chains
- Restore – Create reciprocal alternating activity (using all muscle chains when it is desired).
Reciprocal activity is defined as going from one end-range to another (extension to flexion) and alternating activity is switching from one side of the body to another (right to left stance). When we alternate, the joint on one side of the body ought to do the exact opposite at the other side.
With the above treatment hierarchy, we are working on allowing positional freedom within the person being treated. We call this movement in multiple planes.
Now the Pelvis
This part is where things can get confusing, as we begin talking about pelvic inlets and outlets. The best way to learn about pelvic positioning is to visualize it. So watch the videos below to learn more.
Now our goal for treatment is as stated above: alternating reciprocal function. So when we are in right stance during gait, our right pelvic and thoracic diaphragms should ascend. During left stance, ascension ought to occur on the left thoracic and pelvic diaphragms. In an individual who cannot get out of right stance, these left diaphragms stay descended.
This positioning leads to certain muscles being more facilitated (on), and others being inhibited (off).
In order to get into left stance, we must inhibit and facilitate the following:
- Left anterior inlet
- Right posterior inlet
- Left posterior outlet
- Right anterior outlet
- Right anterior inlet via the right rectus femoris and Sartorius
- Left posterior inlet via the left iliacus through the left anterior gluteus medius
- Right posterior outlet via the right coccygeus and piriformis through the right glute max
- Left anterior outlet via the left puborectalis, pubococcygeus, obturator internus, and iliococcygeus through the left ischiocondylar adductor.
Those Darn PECs
This class is the one that discusses in-depth the posterior exterior chain (PEC) pattern; the one everyone wants to know about.
The PEC consists of the lats, QL, posterior intercostals, serratus posterior, and iliocostalis lumborum. When this chain is turned on, we see the following occur
- Flatter thoracic spine
- Increased lumbar lordosis
- The chain acting as an accessory respiratory muscle.
- Restricted positioning into Right AIC pattern.
- Unilateral hypertonicity restricting contralateral trunk rotation and sidebend.
Basically, this muscle chain throws you into an anteriorly weight-shifted position, thus facilitating increased extensor tone.
Lori stated that 80-90% of the people we will see will have a variation of this pattern. So why is it talked about so little? The answer to that is because under every PEC there is a left AIC pattern. The former is merely a greater protective positioning response.
In this pattern the pelvis looks a little differently than the left AIC pattern:
So with the above positioning and concomitant muscle facilitation/inhibition, we must use different muscle groups to decrease the extensor tone. This strategy will help achieve the reciprocal functioning. In this case, our friends become the internal obliques, transversus abdominis, and proximal adductors via utilizing a posterior pelvic tilt.
The aforementioned strategy is utilized regardless of if your patient/client is non-pathological or pathological. The only difference is that it may take more time to treat one who has a patho pattern.
This is a Test
There were a couple new tests that we learned here to assess the pelvis, which are similar to your typical orthopedic tests.
- Adduction drop (ADT): Basically the Ober’s test; looks at pelvis position
- Standing reach test (SRT): toe touch
- Pelvic Ascension drop test (PADT): Active Ober’s test; looks at the ability of the pelvic outlet to abduct.
- Passive abduction raise test (PART): passive hip abduction ROM; tests if the outlet can adduct.
- functional squat test (FST): getting into a deep squat; similar to if you were going to the bathroom.
- Hruska adduction lift test (HALT).
- Posterior mediastinum expansion test (PMET): Breathe in posterior thorax to assess thoracic flexion.
- Apical Expanstion test (AET): Fill apical chest wall unilaterally to assess trunk rotation.
The above tests are used to determine position and guide treatment. For example, a left AIC would present in the following manner:
- + left ADT
- SRT > 0”
- + Left PADT
- + Right PART
- FST <3/5
- R HALT <3/5
The positive testing above would indicate the pelvis is anteriorly tipped and forwardly rotated, with an adducted left outlet (PADT) and an abducted right outlet (PART).
A PEC would see the above bilaterally, except PART would be negative on both sides.
What was most interesting for me regarding these tests is determining if one is considered pathological or not. It turns out, one can be considered pathological for a multitude of reasons; not just negative Thomas Tests.
For example, take our PEC person above. Say instead of having a negative PART bilaterally, they have a positive PART bilaterally. Since this test result would be atypical, we would consider this patient patho; even if his or her Thomas test is negative. I sadly found out the hard way 🙁
Other ways one could be patho in the PEC route would be if one could achieve a full squat or touch their toes. You only need one thing out of the ordinary to be pathological.
The deciding factor which determines utilizing a pelvis restoration treatment algorithm is the PADT. If after you get someone’s adduction drop test to go negative, and the PADT remains positive, you likely have a pelvic restoration patient/client. Again, this rationale is due to the pelvic outlet remaining in an adducted position, thus not allowing the femur to adduct.
One other clinical possibility that I have found is based off of your HALT scores. Generally (not always), if your patient has low bilateral lift scores (0-1/5 B), you more likely have a pelvis restoration patient. Use your test clusters to guide which route you go.
When the patient is positioned as a Left AIC, we perform activity in the following order:
1st Goal: Turn on right anterior pelvic inlet
How: right rectus femoris and Sartorius
When: + L PADT, +R PART, R HALT 0-1/5
2nd Goal: Turn on left anterior pelvic outlet
How: The left adductors (left iliococcygeus & left obturator)
When: + L PADT, +R PART, R HALT 1+/5 (can start to pick up leg)
Video courtesy of Kevin Neeld
3rd Goal: Turn on left posterior pelvic inlet
How: Left iliacus and left gluteus medius
When: + L PADT, + or – R PART, R HALT 2-/5 (can’t feel gluteus medius during lift)
4th Goal: Turn on right posterior pelvic outlet
How: Right glute max, coccygeus, and piriformis
When: – L PADT, + R PART, R HALT 2 or 3/5
Lori also discussed an inhibition program, which is something I probably have not focused on as much in the past with my patients. Oftentimes if you are not getting the desired changes with the above algorithm, you may have to decrease tone in particular areas to achieve your goal. Here are some possible ways to use inhibition to enhance your program.
Goal: Turn off left anterior inlet
How: Turn on left internal obliques and transversus abdominis
When: + L PADT, + R apical expansion, + L posterior mediastinum
Vid – late left stance with right arm reach
Goal: Turn off right anterior outlet
How: Shut off right adductor via left adductor and glute med
When: – L PADT, + L PART
Goal: Turn off right posterior inlet
How: Get distal fibers of right iliacus via abduction
When: – L PADT, + L PART, decreased right external rotation (<45 degrees)
Goal: Turn off left posterior outlet
How: Via the left adductor
When: + L PADT, + L PART
So now that you have facilitated or inhibited what you need, you likely have the HALT score of 3/5. This value is when one could be “cleared” to stand. So from here, we work towards alternating reciprocal activity aka gait. We progress in the following order:
- Left single leg control
- Right single leg control
- Seated pelvic ascension control
- Reciprocal alternating activity
- Promote squatting
PEC patients (+ Bilateral ADT) go along the exact same route as the left AIC patient, with a couple steps beforehand.
The initial goal is to work on getting one reciprocal, so breathing becomes top priority. Oftentimes with these people you may just work on the basic breathing technique of keeping the ribs down and in, holding position, and breathing.
Once they have adequate technique, we try to inhibit the left anterior inlet and left posterior outlet via abdominals
A patho PEC goes under the exact same protocol, only likely taking more time. Quadruped or standing will be easier positions as the abdominals will not have to work as hard to tilt the pelvis against gravity
That Last 20%
So say you have gotten someone neutral and they feel 80% better. What’s that last 20%? There may be several avenues to consider:
- Respiratory activities (Coordinating extremities with breathing during PRI activities).
- Perform kegels while in left AF IR.
- Focus on seated activity.
- Internal work.
- Check hormones.
- Psychosocial issues.
Can’t get to or maintain neutral
You may run into the case where your tests either won’t go negative or stay negative. We have a hierarchy for that as well:
- Correct breathing technique.
- Inhibition, inhibition, inhibition.
- Make sure patient is feeling desired muscles working.
- Decrease activity aggressiveness.
- Use reference centers.
- Check footwear.
- If hypermobile, get additional support.
If the above do not seem to work, then likely interdisciplinary integration may be needed. More on that to come with future posts.
Shoes and Such
Lori is the resident PRI shoe expert, so we discussed what qualities are needed in shoes. Here are the big things you want to look for:
- A stable and narrow heel counter
- Minimal lateral heel give.
- Flexible lateral toe box
However, if you are able to stay neutral in the shoes you wear, then the above may not be necessary. In certain instances they could be counterproductive. Because these shoes typically have a more elevated heel, if one has other areas driving one into extension (e.g. vision), these shoes could drive extensor tone further.
The Hruska clinic has a recommended shoe list which you may access here.
- “Society is counterclockwise.”
- “Most furniture is designed to fit people who are 5’8.”
- “Monovision is killing us.”
- “Get people off their IPads and IPhones. Go off and do life.”
- “There is nothing wrong with half the gait cycle.”
- “Left AICs are leg whippers with running.”
- “A balloon is like weightlifting for the ribcage.”
- “Mouth breathing promotes extension.”
- “Neutrality is baby bear, not too flexed, not too extended.”
- “Treat by patterns, not by symptoms.”
- “80% of people will get better on basic PRI.”
On the Pelvis
- “Inlet position gives outlet power.”
- “Knee position reflects inlet position.” E.g. knee forward is akin to flexed inlet.
- “The mediastinum reflects the outlet.”
- “PECs will get into left stance by hyperextending the back or the knee.”
- “PECs are pullers versus pushers [in gait].”
- “A PEC walks like a penguin.”
- “Anterior Necks love to be abs for PECs.”
- “High toilets put you into PEC by descending the pelvic floor.”
- “PECs use necks to create thoracic flexion.”
- “When PECs stand, have them pick a leg.”
- “Drop the ribs to get ZOA; don’t round the shoulders.”
- “If you can’t get a good breath in with rounding, check the posterior mediastinum.”
- “When blowing up balloons, don’t get chipmunk cheeks.”
- “If you want to turn off a right QL, please turn on a left ab.”
- “Passive breath in, use everything with the exhale.”
- “If on a computer, look 20 feet away for 20 seconds every 20 minutes.”
- “Balloons, balls, and bands help inhibit.”
- “She’s shaking and I’m getting a little sadistically excited. I’m like that.”
- “You know I’m not usually the funny one so I appreciate it when you laugh.”
- “Is that kinda fun? I think it is, I don’t know about you guys.”
- Jae: “You can’t always get both adduction drops to go.” Lori: “Well I can.”
- “I don’t know everything. I know, that’s shocking.”