Course Notes: PRI Impingement and Instability

Soooooooooo Dense

It has been a long, busy, and great few weeks for me. After attending a cluster of courses, playing around with some new jobs, moving, and working, I got some time to settle down and review PRI’s I&I material.

I traveled to Phoenix to take this course. My man James Anderson taught and several good friends attended. James did not disappoint.

I&I was easily one of, if not the best course I have ever taken. You did it again PRI!

Gotcha!
Gotcha!

The only real disappointment was leaving Arizona. The temperature was in the 80’s and the sun was shining. Now here I am in the Midwest with the temp in the mid-20’s. Why did I stay here again? 🙂

This course combined and fleshed out the concepts of respiration and myokin, and added so many more layers onto what we previously learned.

I&I was what DNS C should have been.

Take notes Prague School. You have potential.
Take notes Prague School. You have potential.

I left the course with many answers, but double the questions. You truly cannot appreciate how complex the nervous system is, and how the total body responds to perceived threat until you delve into this material. I am so excited to learn more.

This course had so much information regarding the entire body that there is no way I could post all the relevant info and do it justice. It really was a 4 day course done in 2. So here are a few of the gems I got from this weekend.

The PRI Basis

The course started off with a lovely frontal-plane slice of the thoracic cavity.

Beautiful
Beautiful

Pay attention to how much stuff is there. This area is money for the body. You will notice the yellow sympathetic ganglia’s proximity to the spine and ribs.

Suppose we alter spinal position. If the thoracic spine is extended and rotated, increased pressure via the ribs and vertebrae occurs to the sympathetic trunk. Thus, when you have someone with a flat and twisted thoracic spine, you may overstimulate the sympathetic ganglia, driving one into sympathetic overdrive.

Depending on which pattern one presents with, different anatomy will press upon the ganglia. A LAIC patterned individual will have the ribs compress against the ganglia due to the rotational component. Whereas the PEC individual’s spine will compress this structure due to the gross extensor pattern.

I am sure that most of you will be wondering about people who present with hyperkyphotic thoracic regions. This posture is still an extended posture. The individual hyperinflates the lungs, while simultaneously flexing the spine to try and dome the diaphragm.

The rib flares are a dead giveaway
The rib flares are a dead giveaway

Now I may be discussing structure quite a bit, but this point must be re-iterated again and again. PRI is brain and autonomic therapy. We are working with a cycle between posture and the autonomic nervous system. Being stuck in the fight or flight state influences our postures, and being in these postures influences the autonomic nervous system.

As James so eloquently put it, preserving the space between the front of the thoracic vertebral body and the front of the back of the ribs will preserve neurology.

Impingement and Instability is Normal

Say what? Yes, you read it right. It is good to be impinging and unstable, as long as these positions are performed at the right time, sequence, and positioned in the right way.  As I step with my left leg, and swing with my right, favorable gait should allow for me to impinge into my left hip for support. That way the unstable right leg can move forward.

To take this concept further, we especially want instability of the nervous system and neutrality. As I defined here, neutrality is a slightly parasympathetic state but having the ability to go sympathetic when needed. We want to be able to phase in and out of neutrality when the situation warrants.

Balanced impingement and instability allows the nervous system to act favorably.

We run into problems when the nervous system creates instabilities to survive sympathetic states. When these defense mechanisms form, impingement occurs to provide stability. The surrounding joints further accommodate these protective patterns by altering position.

Your body will alter itself to keep you alive.
Your body will alter itself to keep you alive.

The Pattern

I could try to write this out for you, but if we look at the entire lower extremity you would lose your mind. Here is a video outlining what happens at every joint, along with how we will get out of that:

For Future Reference

If you can utilize one principle from this course, it is use your reference centers. These areas are where we are trying to create new impingement, new stability points, to shift us more towards a parasympathetic state. They include the following areas:

  1. Right medial longitudinal arch when the left leg is in acetabulofemoral (AF) internal rotation.
  2. The left posterior calcaneal tuberosity.
  3. The left ischial tuberosity.
  4. The left anterior hip capsule/right posterior hip.
  5. Left internal obliques/Transversus abdominis and left posterior lower ribcage (THE MOST IMPORTANT)
  6. Right lateral posterior upper ribs when in left  AF IR.

The goal is to feel as many of these points as possible when not only doing exercise, but through daily activities.

Calcaneal Instability

This portion discussed the subtalar joint’s importance, as its position governs what the entire foot complex does. Therefore, if you do not have good support here, you lose control of the foot.

The calcaneus is the window to achieving frontal plane support and control; a plane not often discussed when designing orthotics. But when you can utilize something like eversion on the right side, you are able to decrease activity of the right adductor magnus and right abdominal wall. Eversion begets increased glute max activity, a PNF concept if I ever saw one.

But not this kind of PNF
But not this kind of PNF

There was also a lot of talk regarding shoes and orthotics. These items are not presented from a support factor as typically done.  By using these devices, we instead are altering the proprioceptive input to the ground-foot interface; thus affecting the position the body is placed.

Femoral Instability

This section discussed correcting potential knee orientations as a result of the pattern. There were many different ways that the femur and tibia could orient or compensate position based on pelvic position. The most potentially nociceptive positions involve the femur rotating one direction and the tibia rotating the other.

The way these can be altered to decrease nociception is by typical PRI fair, with the added focusing on balancing out the hamstrings. Think of these muscles as reigns on a sled. Bias the medial or lateral hamstrings more, and the position of the femur on the tibia can be altered.

Practical Aspects

I got two major points regarding exercising my patients:

1)      Slow down

2)      It’s okay to stand

I had difficulty with progressions through PRI in terms of targeting certain movements/muscles, but also never getting to the point where someone was standing.

Regardless of what activities you choose, you have to be willing to slow movements down so the reference centers and muscles you are going after are felt.

To apply this to standing activity, a PRI-test purist would wait to stand someone until they scored Adduction lifts of 3/5 on both sides. But oftentimes this change can take a lot of time; especially for an inexperienced clinician such as myself. Moreover, people are typically out of painful states before you get to this point. But as long as your patient is feeling the reference centers in the position you are utilizing and your tests are changing…Do it.

Do-It

We also had some great discussion regarding PEC patterns, which is demonstrated via positive Ober’s tests bilaterally and either positive or negative Thomas tests. A  left AIC patient would have only a left positive Ober’s. However, one fitting this pattern could still be a PEC functionally if adduction lift scores were low. You would be oriented in a left AIC pattern, but function as a PEC.

Great James Quotes

  • “The brain will always win.”
  • “There’s a new sheriff in town, it’s exhalation.”
  • “Keeping a patient on a table is great if they are only on a table their whole life.”
  • “Real life PRI is a person walking across the room.”
  • The PEC patterned individual is in bilateral swing phase. “
  • If you get reciprocally alternating gait, you won’t be mobing joints, joints will be mobing you.”
  • “You need the diaphragm in all planes or you will lose.”
  • “PRI is neurology, respiration, and biomechanics.”
  • “The feet are the interface between the brain and the ground.”
  • “In Impingement and Instability, hamstrings are trending on Twitter.”
  • “Airflow drives the nervous system.”
  • “This isn’t muscle training, it is brain training.”

Verdict

Every time I take a course offered by this group I get more excited for my profession and what I do. I can’t wait until my next one. Take their stuff as soon as you can.

I do...Sometimes
I do…Sometimes

11 Replies to “Course Notes: PRI Impingement and Instability”

  1. Another awesome write up . What are the recommendations for those who are in LAIC but have very low adduction lift scores bilaterally or, as you put it , function as a PEC? What sort of PRI exercise selection is suggested?

    1. Thank you for the kind words George. Depends on many other tests such as the thomas test, passive abduction raise test, pelvic ascension drop test, etc. The biggest thing is getting the back to shut off via IO/TA to my understanding thus far.

      The Pelvis Restoration course discusses many of the options for working with people who have low lift scores…Stay tuned ’til January 🙂

  2. Looking forward to it. With all these course reviews I’ll never have to go to a seminar again 😉 will you be at Ifast in march for postural restoration? George.

    1. Hahaha. If only I could cover everything 🙂

      I wish I would be there, but my work is hosting Adriaan Louw that weekend. So still a great course to attend. Will likely go in August to Myokin.

  3. Great write, I’ve been checking back for the last week waiting on your review of the course. I’m taking I&I in May here in NC, and definitely looking forward to it after your review.
    I think PECs are the most frustrating for me currently, so I’m going to order pelvic restoration which will help since I can’t take it live until October 2014.
    Question for you:
    have you purchased or are you using the non manual CDs for exercise prescription – or just making photo copies?
    – Stephen

    1. Thanks again Stephen! Cantrell is great, so I hope you get a lot out of his course.

      I have purchased the nonmanual CDs because they outline things based on category as to what you wish to achieve and progression through each category. It is pretty slick because you can load/email stuff to patients as well. They have been invaluable to me thus far.

      Have to let me know what you think of the pelvis home study; definitely a great thought process regarding people who are PECs.

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