Another Course in the Books

Back in November I had the pleasure of attending a new Baseball PRI affiliate course, taught by my homies Allen Gruver and James Anderson.

I really enjoyed this course because it was such a high-level affiliate and great prep for my PRC. We went into great deal regarding position, throwing mechanics, and treatment.

A…lot…of…stuff.

One of the most amazing pieces of the course was Allen’s ability to breakdown complex baseball movements into their basic biomechanical bits, And from that point show what compensatory things could occur if limitations are present. His eye for these things is unreal.

That piece of the course is a post or two on its own, so I won’t touch it here. In fact, I probably won’t touch it at all. Go to this great class and be wowed by Allen. You will be motivated to become a better clinician. I know I was.

Here are some of the big takeaways.

PRI 101 v 3.0

I’ve heard this overview three times this year now, and it is amazing that I still pick up things from it. James really outdid himself here.

The big piece this time around was space. We want space maximized.

In the vision course we discussed maximizing left peripheral visual space because the pattern reduces this quality. The pattern in general reduces our ability to move through triplanar space.

There are a few other reasons that we would be unable to shift into our left side. Overactive muscles chains may prevent this action, but we also have something very large occupying the left side.

We call this thing air.

If we are hyperinflated in particular areas (think left chest wall), how can we expect to go to the left side? Left space is already filled with air. Airflow must be transferred to the right side in order for us to maximally close down our left. Maximal left sided closure via a zone of apposition is necessary to create true left stance.

Patterns, Adductors, and Pecs (Oh My)

The right adductor magnus and left pec major, though not part of the LAIC/RBC pattern, are still very active muscles. Why is this so? These muscles prevent falling over when in right stance with left trunk rotation.

That PRI Doesn’t Work, I Got Someone Neutral and they Felt Worse

False! Here’s why.

An individual’s norm when under threat is the LAIC/RBC/RTMCC pattern. It’s autopilot; it’s what’s comfortable.

Let’s say you take that away from someone. They have greater movement freedom, but are not sure what to do with it or how to control it. This change could be perceived as a threat by the brain, and symptoms may increase as a means to prevent movement exploration into this new space.

I tell my patients when this happens it is like they just got their driver’s license and I gave them a Ferrari.

A Ferrari is a little more challenging to drive than most cars (so I hear, that blog paper hasn’t hit that level yet), so it’s going to be a bit harder to handle. Once the patient learns how to drive the Ferrari the possibilities are endless.

They must learn a new pattern (RAIC/LBC/LTMCC) in a nonthreatening manner so they obtain locus of control in this new position. Once integrity is achieved here, alternating reciprocal activity is ingrained to maximize movement variability.

Pattern Pitching Problems

Depending on what arm you throw with, you are going to have a bit more trouble with certain aspects of pitching movements. I won’t go into the bazillion reasons why this happens like Allen did (go to the course yo), but here is what each throwing phase needs.

Righties

If I’m a right-handed pitcher, the LAIC/RBC is going to limit me. Let’s break it down to each throwing phase:

• Wind-up – Need to turn on right posterior glute med to delay LAIC activity.

• Stride – Need to inhibit right adductor and QL to maximize stride length.

• Cocking – Need to shift into Left AF IR while maintaining right trunk rotation.

• Acceleration – Need to keep Left AF IR in trunk flexion.

• Follow through – Need to balance into left AF IR.

South Paws

If I’m a left-handed pitcher, the RBC, posterior mediastinum, and timing will be my largest limiting factors. Here is what I need at each component of throwing.

• Wind-up – Need to load left AF IR and engage abs to stay back. Inability to do this is what creates that beautiful natural spin us lefties have when we throw.

• Stride – Need to inhibit LAIC/RBC so one does not rotate too early into Right AF IR and right trunk rotation

• Cocking – Need to control Right AF IR and left trunk rotation while reducing back extension and keeping adequate left posterior mediastinum activity.

• Acceleration – Need to keep trunk closed down into flexion

• Follow through – Need to balance into right AF IR.

Repetitive Rotation Superior T8 (Gasp)

This part was probably the most controversial and misunderstood piece of the course. The concept itself is not difficult to understand, but the material may seem challenging to fit into the PRI philosophy.

I’ve had several discussions with James Anderson on this topic to make the masses get the most up-to-date explanation for this pattern. Here is what we came up with [My post-conversation thoughts will be in brackets].

In the first two baseball courses, “repetitive rotation superior T4 syndrome” was used to describe a rare compensatory pattern seen in particular populations. James and Allen are now calling this pattern “repetitive rotation superior T8 syndrome.” The name changed because there are more ribs reversing the underlying LAIC/RBC pattern then the top 2-4 ribs. This change will be in all future baseball course manuals.

And now for the condition itself. There are certain instances, albeit rare, in which certain individuals may appear to have a reversed postural pattern (RAIC/LBC). Repetitive right trunk rotation occurs via various trauma and/or functional demands, such as the deceleration thru follow-through pitching phase for a lefty or the back swing for a right handed golfer, creating a thorax that is driven to the right.

You can also see this in PRI junkies who bias the left side only and never alternate [Like a right-sided hemineglect neurologically. If right-stance activities are not appreciated, variability may lowered possibly due to disuse. One possibility for this is also losing appropriate right zone of apposition while in left AF IR, to which I will discuss in a future post].

This T8 syndrome differs from classic superior T4 because more drivers push the thorax to the right and externally rotate the right ribs. In the T4 case, the scalenes elevate the upper 2-4 ribs to meet excessive respiratory demands. In T8’s case, the left BC kicks into high gear and drives more of a PEC/bilateral AIC pattern. It may mimic a RAIC/LBC, but not be the case.

With the thorax rotating hard to the right, the pelvis and lumbar spine must orient left and into a pseudo-left AF IR translatory-type movement. Consequently, these folks stand and function quite well on their left leg compared to the right.

Seeing a “flipped” pattern is nothing to freak out about; there are still underlying LAIC/RBC patterning at play. This repetitive rotation superior T8 syndrome is an atypical compensatory strategy that requires atypical treatment.

Interventions basically flip normal PRI activities; shifting into right stance with left trunk rotation. We technically cannot call this “PRI” because the underlying human asymmetry is not addressed.

Treating in this fashion does however put the system into a “normal” asymmetrical pattern to which conventional PRI methods can be used. [That said, the name of the game has always been alternating and reciprocal activity. Everyone should be able to do traditional PRI activities on both sides without falling apart. The reason why this is not called PRI is because of the order treatment occurs in].

[The big message at the end of the day: Trust your measurements and treat accordingly].

Elbow and Wrist Drive Thorax

This portion was one of my favorite pieces of the course; namely because it’s not talked about anywhere else in PRI land.

There are 4 possible patterns on the left and right side that can occur at the humeral-radial joint; depending on the position of each.

I won’t go into details on each, but basically if you see increased mobility in one direction (supination or pronation), you likely want to inhibit that direction and facilitate the converse.

Wrist flexion, pronation, and internal rotation facilitate serratus anterior and contralateral thoracic rotation.

Wrist extension, supination, and external rotation facilitate lower trapezius and ipsilateral trunk rotation.

 Reference centers in the wrist and hand can also be used to facilitate position. When attempting to facilitate left stance with right trunk rotation, use a right pisiform and left palmar arch.

Dat’s It

So there you have it. Some of my favorite pieces from this excellent affiliate courses. It’s filled with a ton of information, and is easily the most challenging conceptually of the three affiliate courses I have taken. You won’t regret this one.

Great James Quotes

• “If you see a forward head, hand them a card that says exhale please.”
• “Inhaling in a state of exhalation is neurologically cool.”
• “It’s not magic. It’s better than magic. It’s neurologic.”
• “We’re gonna talk about trauma called throwing a baseball 95mph with your left hand.”
• “That muscle firing is a total waste of sarcomere slide.”
• “Your brain is a better parent of your body than I was my son.”
• “Ron is looking at the brain, not the plumb line.”
• “A plumb bob and grid is offensive to Ron Hruska.”
• “What have you thought about the fact of never blowing up a balloon as a grown man?”
• “He sucked a lot of balloons empty.”
• “Hand on the heart for serratus anterior. Go ahead.”

 Gruv-y Allen Sayings

• “You are only as good as your patient will allow you to be.”
• “I can’t stand research to a point.”
• “It depends.”
• “The right QL and adductor are best friends…Just like James and I.”
• “Don’t judge someone just by video.”
• “You can’t make a program based on a screen.”
• “If you’re not doing test-retest give them they’re copay back. You are failing them.”
• “One pound dumbbells are not changing my patient’s lives.”
• “We’re facilitating neurology.”