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Course Notes: PRI Pelvis Restoration

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.

PRI 101

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:

  1. Reposition – inhibit muscle chains.
  2. Retrain – Facilitate muscle chains
  3. 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:

Inhibit:

And facilitate:

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

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.

The above tests are used to determine position and guide treatment. For example, a left AIC would present in the following manner:

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.

So…Treatment…Yeahhhhhh

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

Inhibiting

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:

  1. Left single leg control 
  2. Right single leg control 
  3. Seated pelvic ascension control 
  4. Reciprocal alternating activity
  5. Promote squatting

Treating PECs

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:

  1. Respiratory activities (Coordinating extremities with breathing during PRI activities).
  2. Perform kegels while in left AF IR.
  3. Focus on seated activity.
  4. Internal work.
  5. Check hormones.
  6. Diet.
  7. 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:

  1. Correct breathing technique.
  2. Inhibition, inhibition, inhibition.
  3. Make sure patient is feeling desired muscles working.
  4. Decrease activity aggressiveness.
  5. Use reference centers.
  6. Check footwear.
  7. 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:

  1. A stable and narrow heel counter
  2. Minimal lateral heel give.
  3. 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.

Lori-isms

On Life

On PRI

On the Pelvis

On PECs

PRI cues/tips

Funny stuff