Intro

Another retake course is in the books to prep for my PRC testing. This time, it was Myokinematic Restoration with THE Jen Poulin held at Indianapolis Fitness and Sports Training.

This class was my Midwest going away present to myself. IFAST has become a second home to me, and any time I can spend with the folks from there I cherish. Plus ma and pa wouldn’t be too happy with me if I didn’t 🙂

I also had yet to take a course instructed by Jen, so I was very curious to hear her perspective on the PRI science.

I won’t go into the Myokin nitty-gritty like I did here, but what I will do is go into concepts that were cleaned up for me this time around.

Want to know what I learned? Let’s do it!

PRI Patterns = Primitive Reflexes

Ron Hruska just doesn’t make shit up.

Right off the bat Jen stated that the patterns were based off of primitive reflexes that can be elicited in everyone. And for you EBP folks, this is demonstrated here and here.

The left AIC has its origins from the asymmetrical tonic neck reflex, and the PEC from tonic labyrinthine reflex.

and the PEC from the tonic labyrinthine reflex

Jen was the first person to state this claim outright, and to hear it in the basic of basic courses…It made my heart melt.

You Down with Several P’s? Yeah You Know Me.

Another big thing Jen discussed was some very important P-words that if you want to be a PRI Jedi you ought to know:

• Posture – Not static posture you uninitiated suckas. This is an action word. We assimilate many different postures every time we move.
• Patterns – Based off of primitive reflexes. These traits conduct neurology.
• Position – What place is every joint in the body in at a given moment. Can you get out of that position?
• Pelvis – The acetabulum. Important for this course.
• Performance/pain – What most of us work on.
• Parasympathetics – What our end-goal is with PRI.
• Poulin – Yeah, she’s awesome.

Asymmetry

Take these P’s and add the fact that we are asymmetrical creatures, and you have a complex human being.

Our asymmetry is completely normal. We have a heart on the left and a liver on the right. This alone alters which side of the diaphragm will be larger.

The asymmetries don’t stop there. We need to look at the brain to show what really drives us into these patterns. The left hemisphere has more responsibilities for speech and language than the right side. Since the left hemisphere controls the right side of our body, our right upper extremity becomes dominant in how we communicate, grow, and develop. This preference is normal.

What is abnormal is when we rely solely on this right-sided (not handed) preference to live life. When we over-rely on this lateralization, we lose options to move. We lose mobility. We lose system variability.

 The end-game – Live in a balanced state of asymmetry.

That’s a Big Osteophyte. Wonder what He’s Compensating for?

The human system will try its hardest to be able to go left and right; to be able to walk. If my primitive reflexes are not permitting me to do so, then the body will do what it can to compensate.

These patho-compensatory patterns can occur anywhere. Here are some classic myokin examples.

Patho Spine

In the left AIC pattern, the spine and sacrum together orient to the right secondary to left diaphragm and psoas hypertonicity. These muscles contralaterally rotate the spine.

If this chain’s tone cannot decrease, the lumbar spine could attempt to bring the individual to the left side by increasing laxity at the iliolumbar ligament. That is the only way the spine could go left from a right lateralized position.

The lumbar spine does the work that the left hip should be able to do.

Patho Hamstring

Another example could be with the left hamstring. In the left AIC pattern, the left hamstring is elongated secondary to an anteriorly tipped and forwardly rotated innominate.

Upon performing a straight leg raise, this hamstring will appear shorter than the right. This finding occurs because the left hamstring hits end-range earlier secondary to position. The left leg would also appear shorter than the right.

To compensate for various reasons, be it increasing stride length or forward bend capacity, the sacrotuberous ligament could become lax and left hamstring tone could decrease. Again, another strategy to create some semblance of left stance.

Patho Anterior Hip

 Ah, the most famous of all. In the Left AIC pattern, my pelvis is oriented to the right. This puts my acetabulum on femur (AF) into external rotation on the left and internal rotation on the right. My femur on acetabulum (FA) position would be the exact opposite.

Now, if I have to walk forward and not trip over my feet, I could compensatorily externally rotate my left femur so my foot points forward. When external rotation occurs, the femur glides anteriorly. If I do this for a long enough time, my iliofemoral and pubofemoral ligaments could become overstretched, thus creating pathology so hip extension can occur.

PEC. The Ferrari of Compensators

 We are all born left AICs, but the PEC. That’s some next level stuff.

What the PEC individual does is use the right side of the lower back to attempt movement into the left side in the transverse plane. Creating excessive extension keeps one upright.

What limitations occur on the left side, now occur on the right.

Still, it is important to note that many Left AIC techniques will work on PEC individuals because under every PEC is a left AIC.

Muscle Roles – In terms of function

In the left AIC pattern, many secondary movers have to become prime movers secondary to position. In other words, would-be supporting characters such as the TFL try to steal the show.

And we ain’t havin’ that.

The goal then, is to inhibit these chains so prime movers become prime movers and secondary movers know their role.

A couple muscle functions and thoughts that were cleaned up for me:

• Vastus Lateralis – Holds us up when we stand on the left leg in the left AIC, attempting to protect our left anterior hip.
• Adductor Magnus (adductor portion) – Externally rotates the hip in extension. We want this adductor early in the swing phase of gait.
• Obturator internus – Control AF positioning from the other side. They statically hold the pelvis in place so the femurs can do work. Positionally, the left obturator is actively insufficient due to excessive shortening, whereas the right obturator is passively insufficient due to excessive lengthening.

Lift Tests (Gasp)

 Yes. We were fortunate to see the ADDuction and ABDuction lift test at this course. I figured it was about time to show how these work…through film.

First up, we have the Hruska Adduction lift test. This test looks at AF strength and simulates stance phase. Most importantly, the video features Young Matt!

(I say he scores a 5, but after review I’d give him a 4…I got excited).

Here is how it’s scored.

• 0 = Can’t get into position or raise lower ankle off of table.
• 1 = Can raise lower ankle to upper knee.
• 2 = Can raise lower knee and ankle (need to feel IC adductor and glute med on the bottom leg)
• 3 = Can slightly lift bottom hip off table while maintaining position.
• 4 = Can raise hip completely off table.
• 5 = Can raise hip above the level of the patient’s shoulder.

And here is what you go after based on what someone scores.

• 0 = reposition and stretch obturator.
• 1 = Need glute max and posterior capsule to be able to do.
• 2 = Need IC adductor and glute med.
• 3 = Get the glute max to keep AF ER stability and work on left trunk rotation/right arm reaching.
• 4 = Emphasize right trunk rotation/left arm reaching with alternating activity.
• 5 = Take over the world.

The Hruska ABduction lift test was finally demoed this class. It is a higher level beast; reserved for those who can score 3/5 B on the Adduction lift test. This test looks more at the swing phase of gait, and is a tough one to do.

(After careful review, my top leg should’ve kept more IR during part 4&5).

Here is how it’s scored

• 0 = Can’t get into position.
• 1 = Can push bottom hip into surface.
• 2 = Can push bottom foot into wall and lift bottom knee.
• 3 = Can perform internal rotation on the top leg without moving the top pelvis forward.
• 4 = Can raise the top leg completely off the wall and hold without using lateral trunk muscle.
• 5 = Can extend the top leg without back extension, knee flexion, or hip external rotation.

And here is where you go based on the score.

• 0 = Pelvic repositioning if needed; activities that combine adduction on one leg with abduction on the other. Rotation on both. Think lower level combined activities though.
• 1 = Need abdominal activity to perform. Think internal oblique/transversus abdominis.
• 2 = Need IC adductor and glute med to perform.
• 3 = Need posterior glute med on the top leg and anterior glute med on the bottom leg.
• 4 = Need to combine top leg abduction with bottom leg adduction. This activity best simulates midstance.
• 5 = Need top leg glute max while on a stabilized (AF IR) bottom leg.

Clinical Pearls for the Girls (and Boys)

• Gait tweak – Cue someone to take bigger steps with their right leg.
• PRI is very similar to muscle energy techniques (MET). The only difference? Respiration!
• When a repositioning technique occurs, you change the acetabulum, not the femur.
• Perform the standing reach test (toe touch) in an open stance and to either side. This test can help demonstrate if someone is patho or not asymmetrically.
• To cue ankle eversion, have someone push his or her medial malleolus into a small ball.
• If someone is getting TFL cramping during an exercise, they likely need more posterior capsule inhibition.
• PECs have high arches due to the compensatory tibia external rotating.

 Wise Words from THE Jen Poulin

• “Neutral is getting to the start of rehab”
• “If you hold your breath are going to be parasympathetic? Heck to the no!”
• “He liked all my tweets.”
• “Get people in the land of drool. Parasympathetics.”
• “I’m going to treat your back from the front.”
• “What are we going to do this weekend? We’re going to solve mysteries and get Scooby Snacks.”
• “If you have a headache patient please touch her head. But if she has no butt, you will not fix her headaches.”
• “The patella is a sesamoid bone. It’s going to go where it’s told. It doesn’t have a mind of it’s own.”
• “Don’t tape a patella when you’re tonified.”
• “I didn’t stretch her. I shut her down.”
• “We’re all neuro patients.”
• “Neutrality is a place in between.”
• “Get ‘em shut down. Get ‘em purple.”
• “When it’s a crown and jewel to pee on the floor it’s not good.”
• “You don’t have to do PRI activities for the rest of your life, but you better cuddle your dog at the end of your life and be parasympathetic.”
• “Under every PEC pattern is a left AIC pattern. Tweet that!”
• “I can guarantee you and you don’t want to bet against me.”
• “The diaphragm is the core of your core. If you’re not using it, you’re missing the boat.”
• “Always always always downgrade your patient.”
• “What level is she? A big, fat, skinny 0.”
• “He doesn’t count. He’s done PRI. You’re not pure.”
• “All the brain knows is patterns.” ~Ron Hruska
• “Is this your water? I’ll take that risk.”
• “Liz [Messina], can you use your mouth? I know it works well.”
• “Be Bob Ross. Be creative.”
• “It’s fraudulent hip extension. You’re a fake. You’re a fraud.”
• “Your patients are gonna want it.”
• “Pain says stop. Stop being twisted.”
• “Handedness isn’t determined until you’re upright.”