Another Course in the Books

As an official Ron Hruska groupie, the tour continued to the Big Apple to learn a little Postural Respiration.

And in NYC, everything is bigger.

The biggest city I had prior been exposed to was Chicago. The cities feel similar, only NYC has twice as many people on the same size streets.

I felt like this course was one of my less understood areas in the system, as Respiration was my first live PRI course. Taking this class the second time around really cleaned up a lot of things for me, and Ron was on point as always.

So let’s dive into the cranium…I mean pelvis….I mean thorax. Oh sorry, wrong course.

Laying the Foundation

 The three foundational courses aim to inhibit tone, twist, torque, and tension in the human system by various methods.

In Myokinematic Restoration, mastering the frontal plane with both legs inhibits the system.

In Pelvis Restoration, active leg adduction inhibits the system.

In Postural Respiration, trunk rotation inhibits the system.

When these powers combine, the goal is to simultaneously maximize phases of gait and respiration. This development allows for total-body freedom to move, breathe, live, and create amidst our incessant desire to run on our built-in right stance autopilot.

There is nothing wrong with right stance, but it becomes wrong when it is all you know.

“There is nothing wrong with half the gait cycle until it becomes the full gait cycle.” ~Ron Hruska.

Make a Memory – The Zone of Apposition 

Zone – An area that serves a particular purpose

Apposition – The condition of being side-to-side or close to one another.

With these definitions in mind, the zone of apposition (ZOA) is the cylindrical aspect of the diaphragm that lies next to the inner aspect of the lower mediastinal wall.

Since there are few proprioceptors in the diaphragm itself, the ZOA is largely influenced by ribcage orientation. The ZOA flattens if the ribs are elevated, anterior, and in external rotation; and domes in the converse. To maximize respiratory capacity, this space must be persevered at all costs via the rib’s governor—the abdominals.

“You can take my eye before my ZOA.” ~Ron Hruska

Respiratory Influences

 There are many ways that our respiratory system can be influenced. Here are some of the more important ones to think about:

Static asymmetry

• Right diaphragm (respiratory) is large than the left (postural)
• Right vagus nerve is longer than the left

Dynamic asymmetry

• Better lumbopelvic stability on right
• Left thoracoabdominal rotation
• Reach with right
• Better Right ZOA to improve left chest expansion

Breathing discord

• Limited left hemidiaphragm respiratory function
• Decreased right chest wall mobility
• Increased accessory breathing muscle use
• hyperinflation

Abdominal disuse

• Eccentric-oriented rectus abdominis
• Weak obliques and transversus abdominis
• Wide infrasternal angles
• Unilateral or bilateral rib flares

Parafunctional habits

• Being right-sided creatures
• Poor sitting positions
• Mouth breathing

The Result = the Pattern

Factor in the above influences with countless others, we begin to love right mid-stance, aka the left AIC pattern. The left AIC consists of:

• The left innominate being anteriorly tipped and forwardly rotated.
• The left lumbar spine being lordotic.
• The spine being right oriented.

But what happens at the thorax?

The Brachial Chain

 The right and left brachial chain (BC) consist consists of the following muscles:

• Anterolateral intercostals
• Deltoid
• Pecs
• Sibson’s fascia
• Triangularis sterni
• Sternocleidomastoid
• Scalene
• Diaphragm

When the left AIC pulls me into right stance, the right BC compensates to view the environment in the following manner:

• The left ribs externally rotate; the right ribs internally rotate to center the body.
• The thorax abducts to the right and begins rotating to the left (still right-oriented).
• The left scapula is oriented in elevation and adduction; downward and external rotation; appearing retracted.
• The right scapula is oriented in abduction and depression; upward and internally rotated; appearing protracted.
• In the case of the superior T4 syndrome, the right scapula could appear retracted by the subclavius muscle compensatorily.

The Right BC may or may not be present in a Left AIC or PEC individual.  There is also the possibility of someone being a bilateral BC, in which both scapulae protract on the ribcage and bilateral ribs flare. The Bilateral BC is like the PEC of the thorax.

Youz Best Assess

We can assess the BC with very common orthopedic tests, and due to the above positioning, we would expect the following results.

In the right BC individual:

• Decreased right shoulder internal rotation [70-90] (if full, SLAP lesion possible).
• Decreased left horizontal abduction [<35] (if full, costoclavicular hypermobility or left anterior shoulder instability).
• Decreased left shoulder flexion (if full, likely multidirectional instability).
• Limited left cervical axial rotation
• Limited right apical expansion

Apical expansion is when there is anterior and superior movement of the front ribcage.

If one is a bilateral BC, then all motions should be limited on both sides, and if one is a superior T4 (explained later), you would expect limited left apical expansion.

Treatment

 Much like all the introductory courses, right BC treatment is fairly algorithmic. We follow a progression utilizing the BC opposition muscles, which include the triceps, lower traps, serratus anterior, and internal obliques/transversus abdominis. With these muscles, our goal is to create left thoracic abduction, left posterior mediastinal expansion, and right apical expansion.

 ZOA nonmanual –> right lower trap and right tricep.

Here’s a ZOA nonmanual example:

And here’s a right lower trap / right tricep activity:

The right lower trap and right tricep activities work by retracting and posterior tilting the right scapula and rotating the left lower spine; promoting thoracic flexion.

The ultimate goal is to get to right lower trap and right tricep activities, but this progression assumes all your BC tests went negative. That rarely happens, so you may have to use some manual techniques:

 ZOA nonmanual –> ZOA manual –> superior T4

Here’s an example from PRI of one of the manual techniques. There are several so I won’t show you all of them:

Suppose after you do the above and you get a positive left apical expansion test. That would indicate a superior T4 syndrome.

This syndrome is a compensatory pattern that occurs when respiratory demand increases. The right scalanes increase their tone, which externally rotates the upper four ribs on the right. This change would correspondingly result in left rib 1-4 internal rotation.  The vertebrae in this region also begin rotating right.  This rib positioning would explain why apical expansion would be limited on the left.

I ‘splained it here in the video below:

When we run into this pattern, we have to use a few other tricks up our sleeve:

Subclavius manual technique –> left lower trap and left serratus exercise

 The left lower trap and left serratus exercise helps by rotating the mid-thoracic spine to the right, internally rotating the ribs. A desired kyphosis would also be created.

The lazy bear is a good activity to demonstrate this:

Clinical Pearls

 One of the biggest pieces that I picked up from this class regarded patient education. With all the PRI nonmanual and manual activities, our goal is to give the patient a frame of reference. Finding and feeling these movements, muscles, and positions is what helps drive the patient into alternating and reciprocal activity.

We use nonmanual techniques to promote motor learning with these references, and manual techniques are merely a way to guide the patient to these references.

So if anything, the course itself taught me to reinforce why feeling this activity in this area is important to the patient’s experience. How is this technique is going to help them, why do I have to put my hands on your ribcage.  The more we inform the patient the better.

The reference centers are the keys to unlocking the doors of the home under protect mode.

 Conclusion

 So there you have it. Another great PRI course, and my understanding is a little less hazy. I look forward to the next one. If you haven’t made it to a PRI course yet, please do so. You can thank me later.

Wait, you didn’t think I’d forget some good quotes right???? 🙂

 (In)famous Ron Quotes:

• “The appendages tell you what sense you are in. Sympathetic. Parasympathetic.”
• “This is not an anatomical and biomechanics course.”
• “Asymmetry is a gift. Why would you destroy it?”
• “Every muscle you have has a purpose.”
• “If you don’t inhibit something you are dead.”
• “There is no such thing as a shoulder. You have two of them.”
• “There is no such thing as a body.  I see two.”
• “I love fascia, but fascia is not restricting you. Tone is restricting you.”
• “The diaphragm is the only muscle in your body. It’s the first and last one you will use.”
• “You’re treating four patients in an hour? I’m going to pretend I didn’t hear that.”
• “Biological behavior requires unilateral activity.”
•  “Reposition yourself by looking in a true mirror and drinking kool-aid.”
• “70% of patients I see have pain patterns that are illusory.”
• “The only way to look at posture is to look at dynamic activity.”
• “You are only as good as your patient will let you be.”
• “You’re not gonna pop a pill. You’re gonna pop a chest.”
• “People know how to breathe. People need to know how to breathe when they stop breathing.”
• “Evidence-based practice is killing you because you can’t create.”
• “We treat our cars better than our humans.”
• “If you’re going to jump in bed with PRI, jump!.”
• “You know what really screws people up? Selfies.”
• “Based on my limited knowledge of doing this for 35 years…”
• “If you have a bunion, you better get some respiratory shoes.”
• “The first rib controls everything you do in life.”
• “[The posterior mediastinum] should be the sexiest butt on Vogue magazine.”