I had learned so much about what they do in PRI vision that I was feeling somewhat okay with implementation.
Then my friends told me about the updates they made in this course.
I signed up as quickly as possibly, and am glad I did. This course has reached a near-perfect flow and the challenging material is much more digestible.
Don’t expect to know the what’s and how’s of Ron and Heidi’s operation. And realistically, you probably don’t need to.
Your job as a clinician is to take advantage of what the visual system can do, implement that into a movement program, and refer out as needed. This blog will try to explain the connection between these two systems.
If you want more of the nitty-gritty programming, I strongly recommend reading my first round with this course. Otherwise, you might be a little lost.
Prompted by some mentee questions and blog comments, I wondered where manual therapy fits in the rehab process.
To satisfy my curiosity, I calculated how much time I spend performing manual interventions. Looking at last month’s patient numbers to acquire data, I found these numbers based on billing one patient every 45 minutes (subtracting out evals and reassessments):
Nonmanual (including exercise and education) = 80%
Manual = 20%
Modalities = 0%!!!!!!!!!!!!
Delving a bit further, here’s my time spent using PRI manual techniques versus my other manual therapy skill-set:
PRI manual = 14%
Other manual = 6%
As you can see, I use manual therapy a ridiculously low amount; skills that I used to employ liberally with decent success.
There’s a reason for the shift
I want my patients to independently improve at all cost and as quickly as possible. The learning process is the critical piece needed to create necessary neuroplastic change; and consequently a successful rehab program.
I shipped off to Boston to attend my first ever BSMPG summer symposium. And it was easily one of the best conferences I’ve ever been to. There was an excellent speaker lineup and so much of my family. Art Horne really put on a fantastic show.
If you haven’t been to BSMPG before, put it on your to-course list. It is one of the few courses that has a perfect combination of learning and socializing. I hope to not miss another.
Instead of my usual this person talked about that, let’s look at some of the big pearls from the weekend.
Why Sapolsky Doesn’t Get Ulcers
In one quote Robert Sapolsky summed up my current foundational premise to rehabilitation and training:
“The stress response returns the body to homeostasis after actual or potential threats.” ~ Robert Sapolsky
Regardless of what your malady is, it can probably be linked back to the stress response gone awry. The specifics become irrelevant because the stress response occurs nonspecifically.
This response works best against acute crises. Guess how we screw it up? Chronic stressors.
Human stressors are quite different from other species’ as we have the capability of inducing this stress response psychosocially. Gazelles on the Serengeti don’t have to worry about student loans.
We can see how chronic stress becomes an issue when you look at what occurs in the stress response:
Glucose travels to the bloodstream to mobilize energy.
Increased cardiovascular tone, heart rate, and blood pressure.
Decrease long-term building projects such as digestion, growth, and reproduction.
Increase immune system activity
Sharpen cognition, alertness, and pleasure
If the stress response perpetuates, other systems fail and break down to continue to support the need to reduce potential threats. We see a shift in the homeostatic set-point toward elevated levels of the above.
Although we all must deal with stress in some way, why is it that some people tolerate chronic stress better than others? It’s all in how one copes. The following is needed to successfully deal with stress:
Aka good training. But how do we build up individuals to continually better tolerate further challenging stressors?
Here is where my man Eric Oetter dominated the conference.
When chronically stressed, the aforementioned stress response takes high priority in all our systems, including nervous. Immune molecules smudge our various homunculi, dopamine floods the system to reward outputs, and myelin solidifies neurological pathways to perpetuate it.
Breaking a chronic stress cycle involves habit alteration.
To be able to effectively create newly favorable habits, movements, or pathways, attention is key. This piece is something we lose in a stressed state; as prefrontal cortex activity decreases. This is why salience is so important.
To return to a favorable homeostatic environment, we enlist Eric’s three P’s:
Prime brain activity via the aerobic system. It boosts brain power, especially if done before an activity.
How: Work between 120-150 bpm for 15-30 minutes prior to motor skill learning. Do something you enjoy so you do not become overly stressed by the activity itself.
Sleep is a big deal. According to one of the speakers, Vincent Walsh, we sleep 37% of our lives. Yet we only work 19% of them. We sleep so damn much that it should probably be taken seriously.
Sleep helps us remember by helping us forget things. The sleep cycle replays our day; keeping the important pieces and discarding the unnecessary.
This discarding is the pruning that Eric referred to, and it occurs by glial cells. Glia is what smooths out new neural connections.
How do we get good sleep?
Respect the chronotype – keep your normal sleep-wake cycles.
Take naps – 26 minute naps are bomb.
Banish blue light – cut out 1-2 hours before bed, as blue light from electronics tells the suprachiastmatic nucleus in the brain that it is light out.
Become a sleep environmentalist – No caffeine after 12, no meals 3 hours before bed, sleep in a cool room, etc.
If you can’t access to the prefrontal cortex, you will never hit the cognitive stage of motor learning.
Chronic stressors inhibit access to the PFC. The PFC is the doorway to variability, which is something unwanted during a stress response. Automaticity is king.
Getting the PFC allows all systems to be freely expressed. How do we do it?
Monitoring (omegawave, bioforce HRV, etc).
Remove the “neurolock” via redirection and respiration (hint hint– PRI)
Energy systems development.
Respect the Thorax
This section will channel my homie’s James Anderson and Allen Gruver. Can’t go a place without getting a PRI fix.
What keeps the spine and sternum oriented right despite the thorax counter-rotating to the left? The answer would be airflow. A hyperinflated left chest wall pushes these areas to the right.
Thoracic movement is determined by this position as well as timing/coordination of gross movement patterns. We can observe how the thorax is driven through what the extremities are doing.
If you look at the baseball throw, we ought to see alternate positioning on each arm. For example, if the right forearm is in supination during a part of the throw, the left arm ought to be in pronation. This reciprocal arm function promote the thorax rotating in one direction. It’s a PNF thing.
If the arms go in the same direction, the thorax must extend or flex. Since sport is usually extension-driven, we can guess which direction one will go.
Vince Walsh gave an excellent talk on the brain. He thinks we miss lots of talent because we look predominately at physical prowess.
Physicality is only one piece of the puzzle. Some individuals may develop excellent decision-making skills later on in their careers that may trounce athleticism.
Your ability to make right choices and avoid wrong ones is necessary for success, and is a trainable skill.
To know how to train it, it is important to understand the three types of decision-making:
Physical – What to do and not do (e.g. gun slinging)
Mental – e.g. poker playing
Temporal – e.g. playing chicken
Vince predominately used computer simulations to train these decisions, but it seems plausible that these tests could be applied to any type of training. Perhaps something like a reactive agility test could help improve physical decision making as an example. You just have to be creative.
A Cautionary Note on Data
Al Smith said some of the most profound words this weekend. He spoke to caution us on data.
Data does not always tell the individual story, as it can lead to less individualized training or rehab. It dehumanizes both our clients and us. This statement made me think quite a bit to those folks who champion evidenced-based everything.
Perhaps instead of measuring everything, one must first ask if there is a problem with what one is thinking of measuring.
Another cool thing Al Smith showed us was the cynefin framework; a sense making model in which acquired data precedes framework.
Depending on what a situation can be categorized in, one would expect to utilize different thought processes.
Simple – predictable relationship between cause and effect (use best practice)
Complicated – predictable relationship between cause and effect that’s not self-evident (use good practice)
Complex – A system without causality (use safe-fail experiments)
Chaotic – A completely unpredictable system (Use novel practice)
Where does training fit? Where does rehab fit? We may be using incorrect methods in particular situations.
You can learn more about the framework here, it’s definitely something I hope to explore more in the future.
“Too much exercise is not normal hominid behavior.”
“This CT scan was not drawn by a commissioned artist.”
“If you think that’s a tight pec you better check pressure in the air.”
“10,000 hours can’t always undo 100 dumb ones.”
“Frank Netter shut down the left AIC.”
“Deny PNF and you are messing with the system.”
“We’re all barking down the same tree. We just like to complain.”
“No plan survives the first contact with the enemy.”
“Changing the answer is evolution; changing the question is revolution.”
“If you live in mediocrity you eventually think it’s good. You don’t know what good is.”
Back in April I had the pleasure of finally attending PRI’s annual symposium, and what an excellent learning experience.
The theme this year was working with high-powered, extension-driven individuals.
The amount of interdisciplinary overlap in each presentation made for a seamless symposium. Common themes included the brain, stress response, HRV, resilience, and drive. These are things altered in individuals who are highly successful, but may come at a cost to body systems.
If you work with business owners, CEOs, high-level athletes and coaches, high level positions, straight-A students, special forces, and supermoms, this symposium was for you.
And let’s face it; we are both in this category!
There were so many pearls in each presentation that I wish I could write, but let’s view the course a-ha’s.
The Wise Words of Ron
Ron Hruska gave four excellent talks at this symposium regarding high performers and occlusion. Let’s dive into the master’s mind.
People, PRI does not think extension is bad. Extension is a gift that drives us to excel. Individuals who have high self-efficacy must often “over-extend” themselves. This drive often requires system extension.
Extension is a consequence, and probably a necessary adaptation, of success.
If this drive must be reduced to increase function and/or alter symptoms in these individuals, we have to turn down the volume knob.
How can we power down these individuals?
Limit alternate choices – These folks take a wide view of a task
Set boundaries – These folks attribute failure to external factors
Making initial tasks successful – So these folks don’t give up at early failures
Objectively measure improvement – This helps motivate people to continue
Establish rhythmic activity that reflects specific set goals – the higher the goals the more likely the positive change.
A Tale of Two Forward Heads
We discussed a lot of attaining neutrality at the OA joint. What does that entail?
A: Both occipital condyles centered in the atlas fossa with unrestricted lateral flexion.
What is needed to have that?
55-60 degrees of cervical extension.
Equal bilateral first rib rotation position.
Centric occlusion with the anterior teeth guiding protrusive movement and canines guiding lateral movement.
Normal maxillary and mandibular teeth contact.
Ability to nasal breathe.
Alternating pelvic capability.
Normal hearing bilaterally.
Lose any one of these and a forward head posture may occur.
The two types of FHP we see include one with the atlas migrating forward with increased cervical flexion and occipital protraction.
And one in which the atlas migrates backward on the occiput in which excessive upper cervical flexion coupled with lower cervical/upper thoracic hyperextension.
With the former’s case, these individuals have a harder time feeling posterior teeth; a loss of frontal plane. When one loses frontal plane, the individual must attempt to increase anterior guidance via extension. Strategies used to do this include tongue thrusting, bruxism, fingernail biting, mouth breathing, clenching, etc. These strategies are protective in nature as they limit potential stress at the TMJ and OA.
Most of the latter include your bilaterally extended individuals. They retrude the atlas to significantly increase cervical stability. This hyperstability allows for dominant performance in the sagittal plane. These individuals may need more visual interventions.
She’s a Wise Woman
Dr. Heidi Wise gave one of my favorite presentations of the symposium. She discussed vision’s role in extension-driven individuals.
Vision is the most dominant sensory modality, as it has the ability to override all other senses to redirect attention. To me, this is why vision is such a powerful way to get someone neutral.
Redirection of attention through the visual system occurs through saccades. These eye movements occur 85% of the time our eyes are being used. This is how the visual system detects a salient stimulus.
If visual processes hold someone in an extension pattern, it may become extremely difficult to near-impossible to overcome.
Here is how we start thinking a visual process may be promoting an extension pattern:
Those who cannot inhibit extension with traditional floor-up activity.
Late-onset (past puberty) or severe near-sightedness.
People with extremely good eyesight.
Folks who over-focus on objects straight ahead (people who stare).
People who walk with purpose (makes me think of my mom in the mall!).
If someone over focuses (read: nearsighted), eye exploration is minimized. It becomes much harder to notice change, or salience. This is how the visual system can keep someone stuck in a stress response.
What is needed to see close?
Increases in acetylcholine and norepinephrine.
Reflexive increase in neck/head muscle tension. More so if one must strain to see.
Do this too long, and we can see unfavorable autonomic, visual, and neuromuscular stress.
And guess what visual field research is showing we better attune to? The right side; more specifically, the right upper visual field.
The PRI goal? We want to restore ambient vision in these individuals to process three planes of visual motion.
Here were some of Heidi’s recommendations for how to do so.
Take breaks from a task to move.
Be aware of surroundings on both sides without looking when walking.
Walk slower than usual.
Look around using your eyes independent of your head.
If nearsighted, take glasses off occasionally and “be OK” with things far away being blurry. Don’t strain to see well.
Have top of computer screens at about eye level. Look far from the screen as often as possible.
Close eyes and visualize a large open area that makes you calm.
Minimize time on small, close screens and keep object far from eyes.
Read books over e-readers and keep the book as far away as visually comfortable.
Emphasize peripheral awareness before and after high attention tasks.
Change variable such as sounds or environment during high attention tasks.
Strongest memories are tied to emotions; more negative than positive.
If the limbic system is too active (such as in a threatening environment), prefrontal cortex activity goes way down. You can’t learn as well.
Cranial nerves are extremely important in social interaction. Nonverbal cues from these areas can unconsciously affect autonomics.
During adolescence (12-25) the right side of the brain and limbic system develop faster than the left and neocortex. This lateralization is why this time period can be so emotion-driven.
Face to face interaction is needed to cultivate the nervous system. This is the problem with social media and texting.
Dopamine pathways are very active during adolescence; it’s one of the reasons addictions start during this time.
Feelings of being overwhelmed are 6 times more common in those who have had concussions.
Rehearse making mistakes and how you will come out of them.
He also provided some great patient interaction nuggets that I hope to liberally steal.
Keep your eyes on the individual and tell them “it’s great to see you here.”
If you are not doing well on a given day – “I don’t feel good today but we’re going to have a good session.”
If you are at odds with a patient – “We’ve seemed to come to a roadblock. Would you agree?”
My big takeaway from psychologist Dr. Tracy Heller’s talk was mindfulness.
Mindfulness is something I am hoping to get more into in the future. She defines it as being aware of your thoughts, emotions, physical sensations, and actions in the present moment without judging or criticizing yourself or your experience.
It’s a big deal to have this capability. Practicing mindfulness has been shown to reduced cortisol, stress, pain, depression, and anxiety; while also improving memory, sleep, and cognitive function.
The way we build mindfulness is basically letting go. I like the analogy that I heard while using Headspace (a great app if you haven’t used it). Imagine your thoughts and feelings as cars in traffic. Your goal is to just watch the cars pass by, not chase them. You want to be present in the moment, as we want in most of life.
One option of practicing this is resonant frequency breathing, in which we perform 4.5-7 breath cycles per minute. Let the body breathe on it’s own and let the air come in; using terms such as “let,” “allow,” and “permit.” These are cues I have been using much more with patients and has made a big difference.
This was easily my favorite part of the symposium (I may be biased since my Dad gave this talk). Bill Hartman blew it out of the park teaching us how PRI applies at the highest level of performance.
The rules change in the performance realm because the patterns are incredibly powerful, effective, and efficient. In some cases we may want them. A perfect example that Bill gave: Usain Bolt
Rarely does he cross midline when he runs, making him the fastest runner on one leg. Do we want to change that? Probably not.
Performance does not equal health. Gymnasts for example, may need to create pathology to perform at a high level. Some people must utilize passive elements to produce greater outcomes. Usain Bolt runs on one leg. Everyone is a case-by-case basis. N=1 forever.
What must occur in the performance and health realm is stress management. Acute stressors with recovery make us antifragile; prolonged stressors reduce variability as an allostatic adaptation.
If one must constantly perform at a very high level, where will they be on this stress dichotomy? Prolonged stressors = reduced variability, sympathetic dominance, and system extension.
Variability helps us anticipate demand. It helps us become better able to cope with specific environments and recover movement function. The only way we can know if movement variability is present is through assessing the musculoskeletal system
“The state of the musculoskeletal system is the other end of the brain” ~ Bill Hartman
If stressed or threatened, body systems use default reflexive mechanisms to combat threat. The brainstem is much faster than the cortex. As a consequence, variability can be lost.
Attaining increased prefrontal cortex activity allows us to inhibit our default response and increase variability. That’s why mindfulness increases HRV, and that’s why a 90/90 hip lift can alter body position.
To better manage stress, we must train. Training is a progressive desensitization of threatening input to allow an athlete to perform at adaptive potential with optimal variability and without fatigue.
The higher performance level required, the more difficult it becomes to get neutral. This is what happens during functional overreaching. You gain higher performance output during this timeframe because the sympathetic nervous system and HPA axis are on overdrive.
Applying Bill’s principles along the training and rehab continuum, rehab requires neutrality and variability to rebuild a failed stress tolerance. The amount needed in performance realm will depend on how (in)variant one’s sport is.
The Wild World of Combat
Dallas Wood and Zach Nott work with in a military population, and it was fascinating showing how they mitigate the extension necessary for their clientele to perform. They guys collect a lot of data, and the fun factoid was that about 80-90% of their individuals are PEC and bilateral BC (surprise surprise).
They showed us a very cool auditory case. They had a dude with a PEC/BBC presentation with a history of ear trauma and tinnitus. When they blocked his left ear the gentleman was completely neutral.
Treatment underwent reducing the tinnitus by implementing a hearing aid that uses various white/pink noises to slowly reduce tinnitus. Not sure exactly how it works, but this was exciting to hear about (ha). I look forward to learning where PRI takes auditory integration.
So there you have it. I already signed up for next year’s symposium because this one was so much fun. I look forward to more of the consistently fantastic content that PRI provides. Learn on!
I recently had the pleasure and honor of speaking at the annual PRC conference at this past weekend’s Interdisciplinary Integration. I happened to have my younger older brother Connor Ryan record the event.
We unfortunately had some technical difficulties, so a few bits are missing. But you’ll get the gist from the videos below.
You know how sometimes when you are treating someone that individual eventually reveals fairly important information that he or she forgot about.
Yeah that was totally me.
I’ve always had a stuffy nose as far back as I can remember; especially in the winter. The only time breathing felt incredibly easy was when I was eating paleo in college. I have progressively been losing my sense of smell as well.
Must be old age right?
When I spoke with Lori Thomsen about my recent experience, she mentioned at Pelvis that attaining neutrality in certain areas but not others could lead to a “pressure cooker” phenomenon. For example, if I have someone with a neutral neck and thorax, lower extremity symptoms may possibly be more common.
In my case, I had a neutral pelvis at the time my wisdom teeth were pulled. Pull out wisdom teeth and my nasal airway goes crazy. Guess where the pressure went?
It was time to see an ENT.
After viewing my CT scan and airway, my ENT concluded I have patho-scoliosis.
More specifically, airway scoliosis. He found a deviated septum and some enlarged turbinates. These two factors could have a large impact on my breathing capabilities.
To me this made a lot of sense. If you read this article, a nostril will drive air to the ipsilateral lung. So depending on what nasal airway is blocked may dictate whether I am a Right BC or a superior T4.
Moreover, sensory information through the nose travels to the contralateral hemisphere. In my case, my left airway is a bit more open than my right, which would increase sensory input to my right hemisphere.
Per the RTMCC pattern, I actually should have a more open right airway. So this finding would be considered patho per PRI standards. Hence the pathoscoliosis.
Could this abnormality be a contributing factor as to why I am solid on my left side but struggle when I go back to my right? Or even why I’m left-handed? Purely theoretical of course, but something I play around with in my head. I think weird shit like that.
Surgery is not the first line of defense, so we started with conservative measures. I was given a nasal saline rinse and couple nasal sprays to reduce inflammation and symptoms.
Let me tell you, I could notice a difference with the first rinse.
The very first nasal rinse treatment opened up a whole new world for me. I cleaned out the sinuses and immediately measured my horizontal abduction:
20 degrees to 45.
I think I found a new repositioning technique.
The coolest thing? I could smell again. It’s amazing the scents in my apartment and the clinic that I could now pickup that I never noticed before. It was an incredibly rich sensory experience. Sleep quality drastically improved within the first couple nights as well.
The only downside was the effects were not long lasting. It was time for phase two.
Nasal Adductor Pullback
About a month later I went back to the ENT and had an allergy test.
The good news is that I am not allergic to any foods. I can eat anything I want (yay). And actually I didn’t have many allergies at all.
The bad news is that I have a large allergy to perennial rye grass, which is extremely common in AZ. I also have a couple allergies to a few other weeds or molds, but nothing major.
The next step is to try immunotherapy to see if I can reduce my sensitivity to these allergens. This basically amounts to me taking oral drops for the next three years. The hope would be that the threat these allergens are to my system would become nonexistent.
I ought to notice some changes over the next 6 months. If not much symptom-wise is changing, surgery to reduce the turbinates and align the septum will be the likely next step.
If only I could tell the ENT that my symptom was limited cervical axial rotation.
I have this thing when someone uses an uncommon descriptor. When this occurs, I typically try to use an even more ridiculous descriptor.
I especially like to apply this method to wish someone a better day than I. For example:
Joe Blow: “You have a good day.”
Me: “You have an even better day.”
Glorious is a bit more difficult to top, but in the blink of an eye I was able to respond:
“You have a splendiferous day.”
Stupid? Yes. Did I get a laugh and a smile? Absolutely.
Me doing this silly little thing with people is irrelevant. What is relevant is the speed that I was able to apply this quip.
I spouted this word quickly because it fit a common pattern. Pattern recognition is huge in athleticism, medicine, and a multitude of other life facets.
But how often do we think of pattern recognition when we interact with individuals? Being able to differentiate what both verbal and nonverbal communication one uses is critical in ensuring a favorable interaction with someone.
And if your patient or client doesn’t like you? Fugetaboutit.
Let’s look at a very common pattern that if you allow one to persist in will sabotage any connection you are trying to make.
The Double Cross
When you are chatting with someone you ever see this?
In body language realms, crossing of the arms and/or legs generally signifies one is closed off from further discussion. This position subconsciously protects several vital organs and defend from threats.
Change your body position – I will often go and sit right next to them. This posture conveys I am aligned with them. Friends sit side-by-side after all.
Touch – I will touch their arm.
Ask – Ask if they have a question, or what their thoughts are.
Joke – say a funny quip that you have in your repertoire. [Note: If you don’t have a joke set, get one]
Ask if they are cold – Sometimes people cross their arms because they are cold. Regardless of if they are cold, you will redirect attention to their body language. If they are not cold (like living in AZ), they will often change their arm posture. If they are cold, you can change the temp in your office.
Reach – Have them reach for something or give them something to hold onto (a glass of water works great. If I am TNE’ing, I’ll hand them one of my markers).
Open up – make sure when you talk to them you are conveying an open posture as much as possible. Palms facing them and help reel them in.
Change the subject – If you see someone cross their arms when you mention a subject, it becomes clear very quickly that they don’t feel comfortable talking about it yet. Redirect.
To Sum Up
Nonverbal communication is something we all must think about during all of our interactions, and likely plays a huge role in building rapport and buy-in.
Next time someone closes you off, try one of my above strategies and let me know what you think.
Any thoughts or strategies you use to get people to open up? Comment below.