Course Notes: PRI Craniocervical Mandibular Restoration

“The Head and Neck Runs The Show.” ~Ron Hruska

Hello, my name is Zac Cupples, and I have an addiction. I am addicted to attaining CEUs. But not just any CEUs, I want me some of that purple haze from the Postural Restoration Institute.

I got my fix and then some.

This past weekend I was at Endeavor Sports Performance in Pitman, NJ. I got to spend time learning about the neck and the cranium from none other then PRI founder, Ron Hruska.

From the get-go, Ron was adamant in saying that this class was his baby. That this information is what started it all.

And what I learned did not disappoint.

A bunch of happy addicts for sure.
A bunch of happy addicts for sure.

When I took Advanced Integration this past winter, I understood that we were affecting a system, but it didn’t really settle in with me until now. What we are predominately using to affect the nervous system is not specific muscles, but namely triplanar muscle families.

I am not trying to turn on the hamstrings, but I am trying remap the brain’s sagittal plane. I am not trying to turn on the IC adductor, but remapping frontal plane adduction to send me into left stance.

Similarly, we can affect these movement planes with cervicocranial mandibular muscles. It is just another location in the system to which sensory input is applied. Though seeing what outputs resulted will leave you just as surprised as your patients and cleints.

Watching Ron affect a person’s mobility throughout the entire body by manipulating a bite left me awestruck.

You do not realize the power of the human body, the nervous system, and autonomics until you see alterations at seemingly irrelevant areas creating system-wide changes.

I have been so excited to utilize this information clinically, so here is what I learned.

The Boomin’ System

LL is so down with PRI.
LL is so down with PRI.

The introductory courses focus predominately on testing/affecting certain body regions. When you move up to Impingement and Instability, the system slowly ties together via more bottom-up influences.

In this class, we see how we can influence the system from a top-down perspective. We have a new diaphragm that we work with called the maxilla. As we phase through respiration, the maxilla, albeit to a lesser degree, expands and domes via eating activities.

The goal then, is to maximize maxillary position to create thoracic flexion via the sphenoid.

Sphen-what??!?

Yes, you read that correctly, the sphenoid. We played with cranial bones quite a bit in this course. Much like the rest of the body, when I am in right or left stance the cervico-cranial- mandibular bones assume particular positions.

If you have read my reviews on PRI’s myokin and pelvis courses, visualizing cranial positioning will be a breeze. The craniomandibular system mirrors the pelvis (the temporal bones), sacrum (sphenoid) and femur (mandible).

As you can see, the above bones and corresponding motions are quite similar.

When I am in right stance (aka the pattern), my temporal bones and sphenoid are positioned as follows:

  • Left temporal bone: Flexed and externally rotated; an inspiratory position.
  • Right temporal bone: Extended and internally rotate; an expiratory position.
  • The sphenoid: The left-most portion is anteriorly rotated, and the right-most portion is more posteriorly rotated.

Continuing down the pathway, the mandibular region positions as follows:

  • The maxilla orients right.
  • The mandible laterally deviates to the left.
  • The left TMJ capsule: Posterior/medial  (retruded mandible)
  • The Right TMJ capsule: Anterior/lateral (protruded mandible)

And the cervical spine orients as such:

  • Left OA is extended and sidebent to the left.
  • Right OA is flexed and right rotated.
  • The cervical spine is oriented right and left side bent.
  • C2-C6 are flexed.
  • C7-T8 are extended.

An easy way to observe this normalcy, aside from the tests we will do, is to look at someone’s face. Often the following observations can be noted:

  • Full right lateral face.
  • Right temporal indentation compared to the left.
  • Forward, opened, wider, larger right orbit.
  • Right eyeball protruded, left eyeball retruded.
  • More visible left flared ear.
  • Larger and more opened right nostril.
  • Increased distance between side of face and lateral ocular angle on the right side.
  • Elevated right eyebrow.
  • Mandible slightly deviated to the left.
  • Tongue is thicker on the right side, and tends to stick out toward the left.

aka Gary Busey

It is insane how right you are Bill.
It is insane how right you are Bill.

So, our goals here are to protrude the mandible, retrude the cranium, flex the sphenobasilar system, restore cervical lordosis, restore “normal” resting bite, and slight OA extension so the neck is able to turn.

I know I am talking a lot about cranial movement, which I am certain the craniosacral police may come calling. I don’t think that cranial motion is necessarily why we see such changes with these techniques (though cranial bones do move, see here and here).

What seems more plausible to me is the fact that the trigeminal nerve covers so much of this area and is so interconnected towards many body regions.

Moreover, look at the face’s representation in the somatosensory homunculus. It’s huge. Therefore, I feel any input to this region can lead to profound neurological effects.

If you want some literature on how altering bite influences the system, I would check out the following studies here, here, and here (part of my PRC application), as well as my good friend Lance Goyke’s blogs here and here on dentition and foot posture

That’s a Nice Butt You Have on Your Cranium

Now obviously, the craniocervical bones do not just become positioned like this on their own. We have a new muscle chain that helps us achieve right cranial stance called the Right temporomandibular cervical chain, or right TMCC. It involves the following muscles:

  • Longus capitis
  • Superior oblique
  • Rectus capitis posterior major
  • Rectus capitis anterior
  • Temporalis (anterior fibers)
  • Masseter
  • Medial pterygoid

To oppose this chain, we will utilize some of the following muscles:

  • Sagittal repositioners: Left SCM and upper trap
  • Frontal plane abductors: Left rectus capitis anterior and lateralis; longus capitis
  • Frontal plane adductors: Temporalis
  • Transverse plane: Right rectus capitis posterior major and minor, superior and inferior oblique
  • Internal rotators: stylohyoid, styloglossus, stylopharyngeus, left lateral and medial pterygoids.
  • Integration (aka da abzzz): longus colli

If you have taken Myokin, again we can try to make some comparisons to lower quadrant muscles

  • Temporalis = gluteus medius
  • Lateral pterygoid = ischiocondylar adductor
  • Longus colli = Internal obliques and transversus abdominis
  • Suboccipitals = glute max
  • SCM = Hamstring

The Big 3

The only real big three are Jordan, Pippen, and Rodman. However, this class shows us a big three that help us get into a Left TMCC, or more functionally, left cranial stance. And these three muscles are utilized to influence certain bones:

  1. Lateral pterygoid – sphenoid
  2. Temporalis – temporal bone
  3. SCM – temporal bone
I want you to use those Bulls of your cranium.
From left: SCM, temporalis, lateral pterygoid

What predominately moves in this system is the sphenoid. This bone is very thin and airy, thus making it one of the more mobile cranial bones. It is also a very rich location for nervous tissue. The glossopharyngeal, vagus, and spinal accessory nerve all pass through this bone. More ammo to see the cranium as a neurologically-rich area, thus potentially impacting multiple body systems.

Tests

To assess this position, we are not palpating cranial position. Instead, we look at the neck and jaw via:

  1. Cervical axial rotation (total cervical spine rotation)
  2. Mandibular lateral trusion with protrusion

Typically, in the right TMCC pattern, you will see limited axial rotation to the left and decreased right mandibular lateral trusion. These limitations are due to the spinal and mandibular orientation mentioned above.

There are instances in which you may have one but not the other, which PRI would consider “patho.” For example:

  • Decreased Right trusion + non-limited Left axial rotation = OA laxity.
  • Limited left axial rotation + Increased right trusion = TMJ hypermobility.

Treatment

There was actually not many new treatment techniques in this course, as many other activities target the planar muscle families we are trying to use. But I was exposed to a couple new things I really enjoyed.

My favorite exercise from the class focuses on performing a TMCC movement while performing the exact opposite pattern at the thorax and pelvis. So a Left TMCC, left AIC, right BC technique:

The show for me was the manual technique we went over, called the frontal-occipital hold. I had been exposed to this technique before, but learning how to properly perform it has made a huge difference.

It doesn’t seem like much, but clinically I have seen big changes with several of my patients. At this course in particular, Ron was able to increase mandibular opening on a classmate from 30mm to 46 mm. The change in motion throughout the rest of this patients body, as well as his general affect was unreal.

You don’t have to get super-fancy with these techniques, as even performing simple jaw exercises can have profound effects.

Reinforcements

We also learned a couple new reference centers which you can utilize to further maintain changes. These include:

  • Posterior mid-neck
  • Teeth

The more you can feel and contact these areas, the better TMCC neutrality can be maintained.

My other favorite ways to maintain neutrality include:

  • Keeping tongue on roof of mouth behind upper incisors.
  • Keeping teeth slightly apart throughout the day.
  • Make a clucking noise on the palette with your tongue throughout the day.
  • Touch your back upper molars on either side with the tongue.

When to Refer and other Dental Fun

Although I was pleasantly surprised by how much we clinicians can affect this pattern, there are certain cases in which you will need extra help. Here is where dentists come into play.

Referring out usually occurs when structure maintains the right TMCC pattern. It is in the following instances in which you may need to enlist a dentist to maintain neutrality:

  • Can’t contact molars after neutral
  • The jaw and mandible open towards the side of a displaced disc.
  • Really strong open bite.

Not every dentist is going to possess the skills necessary for maintaining neutrality, so the following qualities ought to be sought for in a dentist:

  • Look for a craniofacial dentist.
  • One who uses Alternative lightwire fixation (ALF) splints for palette expansion.
  • Should also be familiar with Elastic Mandibular Appliances for airway management.

Other splints that are good to utilize throughout the day include flat occlusal plane splints. These splints help free up occlusion while working on a PRI program.

When looking for one of these splints, you want diurnal mandibular acrylic splint for two reasons. First off, if your splint in on the maxilla, the mandible is going to have a tendency to create contact by biting. A mandibular splint keeps the jaw relaxed. You also want the splint to be acrylic because we have a tendency to chew plastic, which again would increase jaw tension.

Sometimes pterygoid exercises aren't enough.
Sometimes pterygoid exercises aren’t enough.

 (in)Famous Ron Quotes

On Systems

  • “We are built asymmetrical so we can move.”
  • “Peripheral issues are not working in subsystems.”
  • “I can’t wait to see the day where you succeed at failing [to get into extension].”
  • “90% of patients have a degree of dizziness.”
  • “When you start to play with the body, you play with everything.”
  • “If I have flexion, I can have fun at a party without any liquor.”
  • “If you can’t communicate, you cannot succeed.”
  • [After restoring shoulder and mandibular movement with cranial manual therapy] “Welcome to my world. I am out there alone and I would like some friends.”

On cervical-cranial mandibular Function

  • “I don’t want you to suck at sucking.”
  • “Sucking reduces knee pain.”
  • “The first orthotic you should use is your tongue.”
  • “Cervical Traction is reverse autonomics.” [because cervical lordosis is minimized]

On Muscles

  • “If you want to swallow, you want a levator.”
  • “SCMs take over the world and you lose frontal plane.”
  • “Pterygoids are your built-in CPAP.”
  • “If you want to be orthopedically minded work on a butt muscle and say a lot of rosaries.”
  • “Lats rotate when other areas don’t.”
  • “If you want to treat lats you better move bregmas.”

On the Cranium

  • The head is the fifth extremity.”
  • “The sphenoid knows what the entire body is going through…it owns you.”
  • “Your temporal bone owns trigeminal neuralgia.”
  • “Atmospheric pressure is regulated by a temporal bone.”
  • “The Cranium loves Bob Ross.” [frontal plane = creativity]

On Respiration

  • “People who can’t breathe through a nose have no lips.”
  • “Mouth Breathers are floor addicts.” [Look at ground to get cranial flexion]
  •  “Got nose.”
  • “Oxygen is the new modality.”

On Teeth

  •  “Every tooth you lose makes you unstable.”
  • “Chewing is gait 101.”
  •  “Teeth are passengers on a boat moved by muscles. The way they come out depends on the torque put on the tooth.”
If a picture of Ron in a meat dress being painted by Bob Ross doesn't scream frontal plane than nothing does.
If a picture of Ron in a meat dress being painted by Bob Ross doesn’t scream frontal plane than nothing does.

Chapter 2.1: Dynamic Neuromuscular Stabilization: Developmental Kinesiology: Breathing Stereotypes and Postural Locomotion Function

This is a chapter 2.1 summary of “Recognizing and Treating Breathing Disorders” by Leon Chaitow.

You’re Writing About DNS???!!??!

Yes. Yes I am.

Pavel Kolar and crew actually contributed to quite a few chapters in this edition, and this one here was overall very well written. Believe it or not, it even had quite a few citations!

Well played Pavel, well played.
Well played Pavel, well played.

Why they don’t cite many references in their classes is beyond me, but that’s another soapbox for another day. Onward to a rock-solid chapter.

Developmental Diaphragm

En utero, the diaphragm’s origin begins in the cervical region, which could possibly have been an extension of the rectus abdominis muscle.  As development progresses, the diaphragm caudally descends and tilts forward. When the child is between 4-6 months old, the diaphragm reaches its final position.

Throughout this period, the diaphragm initially is used for respiratory function only. As we progress through the neonatal period (28 days), we see the diaphragm progress postural and sphincter function.

The diaphragm is integral for developing requisite stability to move. Achieving movement involves co-activation of the diaphragm, abdominal, back, and pelvic muscles. This connectivity assimilates breathing, posture, and movement . If this system develops properly, we see the highest potential for motor control.

The largest developmental changes in this system occur at 3 months. Here we see the cervical and thoracic spine straighten and costal breathing initiate. 4.5 months shows extremity function differentiation, indicating a stable axial skeleton to which movement may occur.

Further progression occurs at 6 months. Here costal breathing is fully established. We also have increased diaphragm and lumbar spine stability. This part is necessary for support to occur in the quadruped position, as the proximal attachment of the psoas has a firm place to pull the baby up onto palms and thighs.

Centration Nation I am sure :P
Centration Nation I am sure 😛

In an Ideal World

Per development, an ideal breathing pattern ought to involve the diaphragm descending in the caudal direction, with elastic recoil promoting ascension upon exhalation. As a result, the organs shift caudally as well, and the abdominal wall expands in all directions.

From a muscular perspective, we see an alternating dance of muscle activity. Inspiration requires concentric diaphragm and pelvic floor activity, which compresses the abdominal cylinder to establish intra-abdominal pressure.  Ab wall expansion occurs via eccentric activity of the abdominal muscles, quadratus lumborum, spinal extensors, and hip external rotators. When we exhale, the reverse occurs: diaphragm and pelvic floor eccentrically return to their starting position and the ab wall concentrically tightens up.

Yes, I will dance if I want to. But only, if I want to.
Yes, I will dance if I want to.

Regarding the ribs, we can break them up into segments that do or do not attach to the sternum. The top 7 ribs usually attach to the sternum anteriorly, thus are influenced by sternal movement.

Physiologically normal breathing involves the sternum moving anteroposterior via sternoclavicular joint rotation. It is this movement that contributes to the pump-handle activity of the upper ribs.

The lower ribs laterally expand and open during inhalation, creating a bucket-handle movement. This motion occurs because the thoracic cavity expands anterolaterally by diaphragm and intercostal muscle activity.

But Life Isn’t All Love and Happiness

Breathing sometimes can occur pathologically. One example is paradoxical breathing. Here we see the diaphragm’s central tendon become fixed, leading the diaphragm to be eccentric upon inhalation and concentric upon exhalation. As a result, the lower ribs cranially elevate and intercostal spaces narrow. Accessory muscles begin assisting the breath, creating upper rib elevation.

Because the diaphragm does not assist postural stabilization as well, the paravertebral muscles kick into overdrive to keep us upright.

The sternum begins moving cranio-caudally, the acromioclavicular joint moves instead of the sternoclavicular joint. This change is one reason why we see shoulders elevate with accessory breathing. Hence, we can see why thoracic position is important for creating an ideal environment to breathe in.

These changes can correlate to pain states. In people with chronic low back pain, Pavel Kolar found increased flattening of the diaphragm’s lumbar portion. Another study demonstrated that decreased diaphragm activity during trunk stabilization posed a greater risk for developing low back pain.

ASphincterSaysWhat?

Gotcha!
Gotcha!

The diaphragm can play a large influence on the viscera not only from an intra-abdominal pressure perspective but with digestion as well.

The diaphragm influences eating via the vagus nerve. In order for a bolus to reach the stomach, the diaphragm’s crural portion must relax. The reverse occurs when intragastric pressure must be attained, such as when the esophagus closes off from the stomach contents. So we can see that if diaphragm activity is not up to par, there is an increased risk of gastro-esophageal refux disease occurring.

Don't get gerd.
Don’t get gerd.

Chapter 1: What are Breathing Pattern Disorders?

This is a chapter 1 summary of “Recognizing and Treating Breathing Disorders” by Leon Chaitow.

It’s Been A While

I know it has been a while for some Therapy Notes (©™®#zacistheshizzy), but I decided to revisit some Chaitow as I read his new edition. The chapters have changed quite a bit so far, and many new things have been added. Here is the updated chapter one.

Dedicate this blog to you candy girls out there.
Dedicate this blog to you candy girls out there.

A Lotta History

Hyperventilation disorders have been through the ringer, and to this day are hardly diagnosed. Some of the biggest classifications in my eyes arrived in 1908-09 from phsyiologists Haldane, Poulton, and Vernon. These fellows classified symptoms of overbreathing to include:

  • Numbness
  • Tingling
  • Dizziness
  • Muscular hypertonicity.

This symptom cluster occurred with respiratory alkalosis.

In 1977, Lum, Innocenti, and Cluff developed assessment and treatment programs for breathing disorders in the UK, which spearheaded breathing disorder literature.

Despite these scientific advancements, many physicians do not diagnose hyperventilation as a legitimate problem. Some of these patients even go so far as to being accused as malingering. Hearing this problem is quite unsettling, as I am seeing more and more people who overbreathe; and possibility correlating, more and more people with chronic pain. A future post is in order to show how I think the two are connected.

But I can only connect 1 thing at a time.
But I can only connect 1 thing at a time.

Breathing Pattern Disorders (BPD) and Symptoms

So many symptoms could occur with BPDs. The most extreme of these symptoms is hyperventilation syndrome, defined by the following:

  • Breathing in excess of metabolic requirements.
  • Reducing CO2 concentrations in the blood below normal levels.
  • Altered blood pH towards alkalinity.

Other definitions that ought to be known with these disorders include:

  • Hypoventilation: Increased CO2 levels due to shallow breathing.
  • Hypocapnia: CO2 deficiency in the blood due to hyperventilation; leading to respiratory alkalosis.
  • Hypoxia: Reduced oxygen supply to tissues.

Just How often Should We See This?

Probably more than you think. Hyperventilation Syndrome (HVS) is estimated to occur in about 6-10% of adults.

Of that group, women are 7 times more likely to exhibit these symptoms than men.

Yes! Score one for being a bro.
Yes! Score one for being a bro.

Adaptations

Many different changes occur when breathing is dysfunctional. Most notably, increased accessory muscle use and corresponding decreased tidal volume occur.

When accessory muscles are overactive, the head and shoulders are pulled forward. We also see an increase in lordosis and anterior pelvic tilt. To summate, an anterior weight shift.

Other possibilities that may occur include:

  • Visceral stasis
  • Pelvic floor weakness
  • Fascial restriction in diaphragm’s central tendon.
  • Elevated upper ribs.
  • Affected thoracic spine mobility and altered symptathetic outflow.
  • Accessory muscle hypertonia.
  • Cervical and lumbar spine become progressively rigid.
  • Function is affected in muscles that attach to the diaphragm; including the quadratus lumborum, psoas, and transversus abdominis (cough PRI cough).

With these changes, we may see a shift in body homeostasis to heterostasis if the body exhausts in attempts to adapt. It is these folks that we ought to treat.

You merely adapted your breathing pattern.
You merely adopted your breathing pattern.

A Clinical Case

A fellow coworker/PRI junkie of mine called me over to check out one of his patients.

This gal was complaining of neck pain, headaches, dizziness, nausea, and tingling. She had no vestibular issues at the time. She would flare up with any manual techniques to the neck or traditional headache-based therapies.

Upon observation, she presented with the above general anterior weight-shifted/extended posturing. PRI testing supported this observation.

She was given breathing exercises utilizing a balloon and straw. However, she could not breathe without extending her back. So we decided manual intervention was indicated.

Basically all we did was guide her ribs down and in to assist with exhalation; keeping the ribs down while she inhaled. The interesting thing during this intervention was that she was taking very little air in, but the amount she was exhaling was a ton. Even she was surprised by this finding.

After performing this intervention for about 5 minutes, she got up and had no neck pain. The nausea, tingling, and dizziness were also gone.

This example shows me what power breathing can have in either a positive in negative direction. This girl seemed to be in more of a hyperventilated state. By altering her breathing pattern we were able to influence this status.

Normally this drastic case is not often seen, but I feel that impaired breathing is becoming and will continue to be more prevalent.

Look forward to sharing more.

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.

A good group to learn from and with.

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.

Surely we do not want to move in only one plane.
Shirley we do not want to move in only one plane.

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:

  • Left anterior inlet
  • Right posterior inlet
  • Left posterior outlet
  • Right anterior outlet

And facilitate:

  • Right anterior inlet via the right rectus femoris and Sartorius
  • Left posterior inlet via the left iliacus through the left anterior gluteus medius
  • Right posterior outlet via the right coccygeus and piriformis through the right glute max
  • Left anterior outlet via the left puborectalis, pubococcygeus, obturator internus, and iliococcygeus through the left ischiocondylar adductor.

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.

Oh, you didn't know?
Oh, you didn’t know?

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

  • Flatter thoracic spine
  • Increased lumbar lordosis
  • The chain acting as an accessory respiratory muscle.
  • Restricted positioning into Right AIC pattern.
  • Unilateral hypertonicity restricting contralateral trunk rotation and sidebend.

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.

Good try
Posterior pelvic tilt aka extending lower back. Admirable, but mistaken.

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.

  • Adduction drop (ADT): Basically the Ober’s test; looks at pelvis position
  • Standing reach test (SRT): toe touch
  • Pelvic Ascension drop test (PADT): Active Ober’s test; looks at the ability of the pelvic outlet to abduct.
  • Passive abduction raise test (PART): passive hip abduction ROM; tests if the outlet can adduct.
  • functional squat test (FST): getting into a deep squat; similar to if you were going to the bathroom.
  • Hruska adduction lift test (HALT).
  • Posterior mediastinum expansion test (PMET): Breathe in posterior thorax to assess thoracic flexion.
  • Apical Expanstion test (AET): Fill apical chest wall unilaterally to assess trunk rotation.

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

  • + left ADT
  • SRT > 0”
  • + Left PADT
  • + Right PART
  • FST <3/5
  • R HALT <3/5

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 🙁

Cue Sarah McLaughlin. Taking donations today.
Cue Sarah McLaughlin. Taking donations today for the Patho PEC support group.

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.

So make sure the shoes you get work for you.
So make sure the shoes you get work for you.

The Hruska clinic has a recommended shoe list which you may access here.

Lori-isms

On Life

  • “Society is counterclockwise.”
  • “Most furniture is designed to fit people who are 5’8.”
  • “Monovision is killing us.”
  • “Get people off their IPads and IPhones. Go off and do life.”

On PRI

  • “There is nothing wrong with half the gait cycle.”
  • “Left AICs are leg whippers with running.”
  • “A balloon is like weightlifting for the ribcage.”
  • “Mouth breathing promotes extension.”
  • “Neutrality is baby bear, not too flexed, not too extended.”
  • “Treat by patterns, not by symptoms.”
  • “80% of people will get better on basic PRI.”

On the Pelvis

  • “Inlet position gives outlet power.”
  • “Knee position reflects inlet position.” E.g. knee forward is akin to flexed inlet.
  • “The mediastinum reflects the outlet.”

On PECs

  • “PECs will get into left stance by hyperextending the back or the knee.”
  • “PECs are pullers versus pushers [in gait].”
  • “A PEC walks like a penguin.”
  • “Anterior Necks love to be abs for PECs.”
  • “High toilets put you into PEC by descending the pelvic floor.”
  • “PECs use necks to create thoracic flexion.”
  • “When PECs stand, have them pick a leg.”

PRI cues/tips

  • “Drop the ribs to get ZOA; don’t round the shoulders.”
  • “If you can’t get a good breath in with rounding, check the posterior mediastinum.”
  • “When blowing up balloons, don’t get chipmunk cheeks.”
  • “If you want to turn off a right QL, please turn on a left ab.”
  • “Passive breath in, use everything with the exhale.”
  • “If on a computer, look 20 feet away for 20 seconds every 20 minutes.”
  • “Balloons, balls, and bands help inhibit.”

Funny stuff

  • “She’s shaking and I’m getting a little sadistically excited. I’m like that.”
  • “You know I’m not usually the funny one so I appreciate it when you laugh.”
  • “Is that kinda fun? I think it is, I don’t know about you guys.”
  • Jae: “You can’t always get both adduction drops to go.” Lori: “Well I can.”
  • “I don’t know everything. I know, that’s shocking.”
If you can blow these up you will be a tank.
If you can blow these up, you will be a tank.

The Year of the Nervous System: 2014 Preview

It’s All Part of the Plan

And if you see my course schedule this year, the plan is indeed horrifying.

joker

I wanted to write a post today to somewhat compose my thoughts and plans for this year, as well as what I am hoping to achieve from the below listed courses.

Because of the course load and some of my goals for the year, I am not sure what my blogging frequency will look like. I have begun to pick up some extra work so I am able to attend as much con ed as I do.

Yes, this will be me from time to time for now.
Yes, this will be me from time to time for now.

The Amazon affiliate links that I don’t get money for because I live in Illinois simply cannot pay for classes :). I am just putting these links up here because I want to encourage you to read these books on your own. Use my site as a guide through them.

Big Goals

My biggest goal for this year is to successfully become Postural Restoration Certified (PRC), and my course schedule below supports this goal.

The amount that I use this material and the successes that have come along with it simply compel me to become a PRI Jedi. I see the PRC as a means to achieving this goal.

The application thus far has been quite time-consuming. There are a total of 3 case studies, 5 journal article reviews, and tons of other writing that has to be done. Couple that with studying the material, and I have had a very busy year.

I also hope this year to start offering some online training at some point. I do some personal training on my own in my free time (ha), and would like to extend my services to people who are not near me. This would come complete with a full skype evaluation and unlimited access to me via email for all your questions, comments, concerns, and complaints.  If anyone is interested, please contact me at cupplesperformance@gmail.com

This will NOT be you on my programs.
This will NOT be you on my programs.

Without further ado, here is the course list.

Course List 2015 aka “The Year of the Nervous System”

I have dedicated this year to maximizing my understanding of the most powerful way to get into my patients, here is the lowdown

January 17th-18th – PRI Pelvis Restoration, St. Louis, MO

Been so looking forward to this class. Here I hope to learn about decreasing extensor tone in those people who use it as their protective pattern. Extension is what gives us power in response to defend from threat, this course will help you turn it off when you need to.

February 8th-9th – PRI Cervical-Cranio-Mandibular Restoration, Pitman, NJ

There are several patients that I just seem to have a harder time with. People with neck pain are one of them. Moreover, there are some patients who I just can’t seem to get fully neutral from a PRI perspective. I am hoping to learn to what extent I can affect the neck and above to help my patients achieve better function.

February 15th-16th – Explain Pain, Atlanta, GA

I have already taken this course once, but the man, myth, and legend David Butler is teaching this version. EP is his baby, his muse. If I won’t ever be able to see Led Zeppelin live, interacting with Butler would be the next best thing.

Total rockstar in my eyes.
Total rockstar in my eyes.

March 1st-2nd – Therapeutic Neuroscience Education: Educating Patients About Pain, Naperville, IL

I have been fortunate enough to chat with Adriaan on multiple occasions, and have the pleasure of hosting him where I work. It will be nice to get his perspective towards pain education. Adriaan was who I took Explain Pain with, and I will be curious to see how his thought process has changed since a couple years ago.

March 29th-30th – PRI Postural Respiration, New York, NY

Another re-take course for me. But this time, I have much more experience with the system. I hope my understanding will be so much more enriched. Plus, I get to learn it from Ron. Anytime you can learn from this man please do.

April 26th-27th – PRI Vision, Grayslake, IL

The motor system is not the only thing that can put up defense mechanisms in response to threat. The visual system changes as well, and in many cases can drive one’s protective postures. I need to know why and how.

May 2nd-4th – Dermoneuromodulation, Chicago, IL

The skin is such a sensory-rich organ that I need to learn more about it. And who better to learn it from then the master-ectodermalist Diane Jacobs. I have yet to take a true hands-on course, and if I can learn a pain-free way into the nervous system, then sign me up.

Hopefully I can teach her some therapeutic Microsoft paint techniques in return 🙂

True dat
True dat

June 7th-8th – PRI Integration for the Home, Lincoln, NE

Sometimes the PRI movements can be very challenging for those who are older. I want to know how my man James Anderson gets this population to perform at the high level he does. I want the baked goods!

Also during this week I plan on netting some observation time at the Hruska clinic. Details to follow.

August 9th-10th – PRI Myokinematic Restoration, Indianapolis, IN

I took this class last year, and want to be as prepped as possible for the PRC. Besides, Indy is my Mecca. I have so many good friends there that I cannot pass up a chance to hang at IFAST.

October 18th-19th – Neurodynamics and the Neuromatrix, Buffalo, NY

With two rounds of Explain Pain and Mobilisation of the Nervous System under my belt, what better way to put the classes together? Plus I am hoping to get my man Erson Religioso to come so we can hang out (hint hint).

November 1st-2nd – NOI Clinical Applications: Lower Limb and Lumbar Spine, Chicago, IL

I am going to this one mainly to cleanup my techniques and though process, as well as learn a little more about the less talked about nerve tracts (that darn saphenous nerve).

November 21st-22nd – PRI Integration for Baseball, Clearwater, FL

Florida in November…no brainer 🙂

But seriously, getting little snippets throughout my previous classes about what they will be teaching here has me intrigued.

Most of PRI deals with gait, which if we talk DNS is a contralateral pattern. Here my understanding is how PRI will approach the ipsilateral patterns. They will also introduce a test for the thorax, hopefully giving me a nice adjunct to the Hruska Adduction lift test.

December 4th-9th – Advanced Integration and PRC testing, Lincoln, NE

AI was such a game changer for me this year that I cannot wait to take it again. There are so many nuances I want reinforced and so many questions answered.

Moreover, the PRC test is going to happen, and learning in close proximity with Ron, James, and Mike is an opportunity I simply cannot pass up.

C’est Fini

So there’s the plan for this year. What thoughts do you have? What’s on your con ed radar for the year? Comment below.

What I use to find the best con ed courses there are.
What I use to find the best con ed courses there are.

Course Notes: Advanced Integration Day 4 – Curvature of the Spine

Today we get wild and crazy and talk about scoliosis and the like; the last day of AI.

For day 1, click here

For day 2, click here

For day 3, click here

Scoliosis Variations

The entire day focused predominately on treating scoliosis, which oftentimes amounts to exaggerations of the common patterns PRI discusses.

Because scoliosis is an exaggerated PRI pattern, one must beget the question if the pattern or scoliosis came first? This question obviously cannot be answered, but for our intents and purposes we ought to assume pattern precedes curve. That way we may be able to alter the impairment.

Hide your curves, hide your right.
Hide your curves, hide your right.

The scoliosis we can alter is often functional aka rotational. These types are ones that everyone has; the question is to what degree.

Nonpathological Curve

The nonpatho curve is an exaggerated version of the LAIC/RBC pattern, oftentimes with superior T4 syndrome involved. In this pattern the left ribs are externally rotated and right internally rotated. This reason is why 98% of scoliosis has right sided rib humps. A rib hump is akin to excessive rib internal rotation.  In this case, the spine looks like so…

Yep, he's still got it.
Yep, he’s still got it. [Adapted from PRI manual]
Here we can see how the spine excessively right orients up to T8-T9, then rotates left superior to that.

These patients will present with typical Left AIC and Right BC test results along with typical right lateralization. One difference may be the right shoulder is not as low as typical with most patterned individuals. This change is due to compensating for the excessive curve.

When treating, these people like most everyone need a ZOA. The steps to treat are as follows:

  1. Get neutral at the pelvis
  2. Get right apical expansion 
  1. Get right low trap and right tricep

Pathological Curve

With a pathological curve, we see basically a RAIC/LBC pattern, which amounts to a body in left stance with a brain that is right lateralized

My drawing ability is patho.
My drawing ability is patho. [adapted from PRI manual]
Here we see the opposite of the non-patho curve; a left oriented lumbar spine from L3-5 and right oriented thorax. What makes this curve pathological is because the pelvis is still right facing. Thus, the spine below T8 stays rotated to the left. This patient may present with a rib hump on the right upper thorax and possibly on the left lower thorax.

The hypothetical reason for this curve’s occurrence is to achieve a pseudo-left stance. A patterned individual will have difficulty getting into left stance; in particular left acetabulo-femoral internal rotation (AFIR) on the left hip. So to compensate, the lumbar spine curves left; essentially becoming the left hip.

This patient will present as a left AIC with or without typical right BC test results.  Because testing may be inconsistent, it is very difficult to tell if one has a pathological curve unless you have an x ray.  Their center of gravity is shifted to the left because the spine is shifted as such.

Our treatment goals will essentially involve aligning the pelvis with the lumbar spine, but the progression is different from normal PRI style. Reason being is due to these patients not presenting “normally” per PRI standards.

With the lumbar curve compensating for a left hip, top priority is getting the hip back via AFIR

From here, we progress in the following manner:

  1. Alternating activity via left femoral-acetabular (FA) IR & adduction with with FA abduction 
  2. Upright left AFIR with right trunk rotation

Kyphosis

People who have excessive kyphosis in the upper and lower thoracic regions love using their low back a little too much. Therefore, this issue is mostly a sagittal plane problem.

These folks will usually present with inability to perform a toe touch. This impairment results from short and weak hamstrings combined with overactive pecs and lats. Oftentimes the SCM will be overactive too, thus creating a forward headed posture.

We see other influences that may contribute to one developing excessive kyphosis:

  1. Hyperactive iliacus that pulls the pelvis anterior.
  2. Long active psoas.
  3. Short serratus anterior to contribute to rounded shoulders.
  4. Decreased apical expansion bilaterally.
  5. Hyperactive anterior temporalis
  6. Compensatory overactive pterygoids.

Therefore, when treating, our goal is to get the spine frontal and transverse planes. The way we do this is by inhibiting the lats while getting us some activity on elongated hamstrings

A Q&A Tidbit

Once the course material was finished, we had a great Q&A session with Ron, James, and Mike. Many points were clarified, and we got a big gem from Mike regarding the infrasternal angle.

Using this angle is a great way to cue ZOA. Assuming 90 degrees is “normal” and what we want to shoot for, there may be two ways to achieve this number depending on one’s starting point.

–          Wide infrasternal angle: Tell the patient to exhale and make their angle 0 degrees (they can’t obviously).  Keep the angle at that value while breathing.

–          Narrow infraternal angle: Put the patient in sidelying to further bias the obliques and shut off rectus abdominis.

Final Thoughts

Whew.  So there you have it. Four days of some of PRI’s finest material. I will definitely have to retake this course to fully grasp it, but assimilating the bit of info I had seems to be making a difference in how I practice this methodology.

Moreover, I am so excited to continue learning more from them next year. I cannot recommend this information enough.

(In)famous Ron Quotes and Great James Quotes

  • “The best orthotic you have is your brain.”
  • “The more you put on somebody, the more unstable they are.”
  • There’s an orthotic I’d never want on my spine. It’s called a rod, brace, or jacket.”
  • “The brain is the big kahuna.”
  • [regarding the rules of the Hruska Adduction lift test] “You’re breaking kindergarten rules. Your nap is over. You’re in first grade.”
  • “Fixing stuff in swing is the show. It’s feed forward.”
  • “It’s not a neocortex. It’s a paleocortex.”
  • “Don’t take me literally, but take me literally.”
  • “Modify one’s passions to be successful.”
  • “People don’t get their hands overhead enough.”
  • “Running is not alternating activity; running is momentum.”
  • “When you reach, you risk. But you must reach without losing a reference center.”
  • “[Shoulder] Internal rotation is a party trick at best if you aren’t alternating and reciprocating.”
  • “[James on geriatric patients] If you don’t integrate you won’t get the baked goods.”
  • “Cobb method has nothing to do with respiration.”
  • “The orientation of the vestibular system drives everything.”
It was a pleasure making it to first grade because of these gentlemen.
It was a pleasure making it to first grade because of these gentlemen.

Advanced Integration Day 3: Thoracic-Scapula Integration

Day 3 was all thorax and scapula. Here we go!

For day 1, click here

For day 2, click here

A Philosophical Ron Intro


Since the day began talking thoracic-scapula, Ron started us off by showing all the T-S connections in the body.

Temporal——-sphenoid

Thoracic———sternum

Thoracic———scapula

Tri-os coxae—-Sacrum

You will notice that the thorax is very connected to many of these areas. Therefore,  it is very important to control this area early on; especially if one’s problem is in the cervical spine.

The “pattern” dictates the thorax governing the cervical spine because the neck follows suit with the rotated left thoracic spine. Thus, if we restore position to the thorax, oftentimes neck position will clear up.

From here, my man James Anderson was introduced, and we started off the
discussion with a bang.

And bang he did.
And he moved…he moved

Brain, Brain, and a Little More Brain


The first hour was spent talking about a subject much needing discussion: PRI’s cortical foundation. James really hammered the fact that our brains are what drive us to the right.

None of the previous mentioned material matters. Zones don’t matter, left AFIR, right shoulder internal rotation, nothing, if you can’t get the brain to change out of a left hemispheric dominance.

How do we do this? Per James, let’s get a zone of apposition (ZOA) in a right
lateralized pattern.

SayWhat

Say what? All the talk you have been hearing involves getting out of this right-sided dominance. But think of PRI activity in this fashion. We are most comfortable with performing right-sided activities. So why not use graded exposure to slowly get us onto our left side? Since ZOA establishment is the foundational piece, let’s just get that and slowly work towards using our left side.

The activity above was something James showed us at Impingement and
Instability. As you can see, my pelvis orients to the right and thorax to the left with this activity i.e. the pattern. However, James got one of my classmates neutral with this exercise. Because we achieved ZOA in the pattern, the brain can safely begin to lateralize to the left without a threat response sending us back into our comfortable right dominant pattern.

Come with me if you want to get into left stance.
Come with me if you want to get into left stance.

Explaining Superior T4


Superior T4 syndrome is another PRI concept that for me was very difficult to understand. But after AI, this syndrome was cleared up for me.

In a normal patterned individual the left ribs are externally rotated and in an inhaled state, and the right ribs are internally rotated in an exhaled state.

In a superior T4 syndrome, the first rib becomes elevated anteriorly on the right. This change occurs when the scalenes begin to act as accessory respiratory muscle.

Overactive scalenes will alter rib orientation down to T4 level because that is the level the first rib is located at.

Pretty close as you can see.
Pretty close as you can see.

When this elevation occurs, ribs 1-4 internally rotate on the left and externally
rotate on the right. This pulling creates torsion in this area, thus altering rib
orientation and the movement synchrony of the ribcage.

The internally rotated left upper ribs decrease apical airflow simply because there is no rib expansion. This airflow type leads to corresponding decreased shoulder internal rotation bilaterally and impaired
subclavius mobility secondary to rib and shoulder girdle compensatory positioning.

Postural Respiration on Steroids


James gave a very clear explanation as to why certain muscles are targeted in a right BC pattern. Let’s discuss them below.

Since it is almost NYE
Since it is almost NYE

Right low trap – Based on the thorax’s orientation in a patterned individual, the right low trap is long at both ends.

  • Kinda Too Good at: The lengthened right trap helps stabilize the right abducted thorax poorly by partnering with the right ab wall.
  • Goal: We want the low trap to retract and posteriorly tilt the protracted scapula, as well flex the thorax.

Left low trap – Based on the thorax’s orientation in a patterned individual, the left low trap is short on both ends.

  • Too good at: The left trap does very well concentrically stabilizing spinal rotation in the transverse plane secondary to shortness.
  • Goal: We want the left low trap to help stabilize a left abducted thorax.

Left Serratus Anterior – Shortened due to thoracic and scapular position.

  • Too good at: Left serratus drives the thorax into right abduction to further facilitate favorable right hemidiaphragm position.
  • Goal: Improve thoracic kyphosis sagitally and promote rib IR via upper fibers to drive thorax out of left rotation transversely. Will help anchor ZOA because ribs retract and increase left posterior mediastinum activity.

Right Serratus Anterior – Lost leverage by scalenes and abdominal wall shortening the surrounding areas, thus making serratus long.

  • Too good at: Sagittal activity.
  • Goal: Drives the thorax into left abduction to quiet the right ab wall and scalenes. Also externally rotate ribs to increase apical expansion.

Right Subscapularis – Mechanically disadvantaged against the lat and pecs due to scapular position.

  • Too good at: Not much. Trouble overpowering the lat
  • Goal: Will keep the lat quiet once thorax and scapula are properly positioned. If your patient/client has positive RBC tests except full shoulder internal rotation, then some issues once all these tests are clear, go after this muscle.

(In)famous Ron Quotes

• “Give the least amount necessary to be successful. Need to get you there and
then take it [the activity] away.”
• “God love ya, but I just don’t want to focus on provoking pain.”
• “If you gotta travel with pillows, you got issues.

Great James Quotes

• “The brain is right lateralized. Your 12 o’clock is not 12 o’clock.”
• “The brain is the heart of integration through the thorax.”
• “When your soul burns, you’re integrated.”
• “If you think you’re feeling your ab wall, I think you are not integrated.”
• “Don’t fight the brain.”
• “If you leave the brain on the table, you are not playing.”
• “I’m like Dr. Seuss. I’ll get a ZOA in a box, I’ll get a ZOA with a fox.”
• “Breathing and autonomics are the same word.”
• “If you think it’s AFIR you missed the show. You are at my daughter’s third
grade magic show and I’m at Vegas with David Copperfield.”
• “Your ab program is likely a neck program.”
• “John Wayne knows how to work serratus.”
• “When subscap becomes subscap, it will give you internal rotation
everywhere.”

This man can get ZOA with a bat. He can get a ZOA on a cat.
This man can get ZOA with a bat. He can get a ZOA on a cat.

The Post Wonderful Time of the Year: Top Posts of 2013

The Best…Around

Time is fun when you are having flies. It seems like just yesterday that I started up this blog, and I am excited and humbled by the response I have gotten.

Hearing praise from my audience keeps me hungry to learn and educate more.

I am always curious to see which pages you enjoyed, and which were not so enjoyable; as it helps me tailor my writing a little bit more.

And I’d have to say, I have a bunch of readers who like the nervous system 🙂

Like porn for my readers.
Yeah, it’s pretty cool

I am not sure what the next year will bring in terms of content, as I think the first year anyone starts a blog it is more about the writing process and finding your voice.

Regardless of what is written, I hope to spread information that I think will benefit those of you who read my stuff. The more I can help you, the better off all our patients and clients will be.

So without further ado, let’s review which posts were the top dogs for this year (and some of my favorite pics of course).

10.  Lessons from a Student: The Interaction

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Actually, I have found I now have more success setting up my interactions like this.

This was probably one of my favorite posts to write this year, as I think this area is sooooooo underdiscussed. Expect to be hearing more on patient interaction from me in the future.

9) Clinical Neurodynamics Chapter 1: General Neurodynamics

Any post with Predator in it has been shown to increase T levels by 300%
Any post with Predator in it has been shown to increase T levels by 300%

Shacklock was an excellent technical read. In this post we lay out some nervous system basics, and why we call neurodynamics what we call it.

8) Course Notes: Graded Motor Imagery

Drawing skillz unparalleled.
Drawing skillz unparalleled.

It seems like I took this course forever ago, but reviewing this post reminded me why I love the NOI group so much. I feel as though their message is one you cannot get enough of.

As for GMI itself, I find that it is great for people who most every movement hurts, as well as an educational piece. From a PRI perspective, it is also useful. I have had patients imagine contracting their glute max and go neutral. Crazy stuff.

7) Explain Pain Section 6: Management Essentials

I totally recall how awesome this post was...Just see the movie
I totally recall how awesome this post was…Just see the movie

Hopefully after following this blog you have a better understanding of pain than the average bear, so here are some basic ways we can manage the pain experience.

6) The Sensitive Nervous System Chapter III: Pain Mechanisms and Peripheral Sensitivity

When I see someone stub their toe, I'm not thinking a stubbed toe.
When I see someone stub their toe, I’m not thinking a stubbed toe.

One of my very first posts, so maybe a Cupples classic?

Anyway, here we explore in great detail what nociception and peripheral neuropathic pain are; and why you should go to the emergency room when you stub your toe 🙂

5) Course Notes: PRI Myokinematic Restoration

Because why not?
Because why not?

I am very glad this post got many views, as I feel the message these guys send is some of the best on the market. Here is PRI 101, and expect to hear a lot more about their work this upcoming year.

4) The Sensitive Nervous System Chapter VIII: Palpation and Orientation of the Peripheral Nervous System

There was a time in which I didn't post funny pics...Besides, who doesn't like Led Zeppelin?
There was a time in which I didn’t post funny pics…Besides, who doesn’t like Led Zeppelin?

One underrated way to assess the nervous system is via palpation. You can get a lot of interesting responses on people. Here we learn how.

3) Clinical Neurodynamics Chapter 2: Specific Neurodynamics

I really feel like my artistic endeavors became their own once I started drawing in color.
I really feel like my artistic endeavors became their own once I started drawing in color.

In this post we learn a lot of local nervous system tidbits, and more information on my future Therapeutic Microsoft Paint Course 🙂

2) Course Notes: Mobilisation of the Nervous System

That my writing pace has slowed down.
That my writing pace has slowed down.

Such a great class. Here we see updates to the science behind “The Sensitive Nervous System”, as well as some neat tweaks to our neurodynamic testing. My favorite pieces were on the immune system and genetics.

1) Explain Pain Section 1: Intro to Pain

Because what's a post on my site without a Bane reference?
Because what’s a post on my site without a Bane reference?

This section could be a manifesto for this blog. Learning and understanding pain has been one of the biggest game changers for me as a clinician and writer.

Simply put, if you work with people in pain, this section is a must-read.

C’est Fini

So there you have it. Which posts were your favorite? Which would you like to see more/less of? Comment below and let a brother know.

eded210603aebe99ec87aca519cabe376f

Advanced Integration: Day 2 (Triplanar Activity)

For day 2 we discuss more and more the areas that help support ZOA establishment. Read on comrades.

For day 1, click here

Neutral

Neutral can be described as a position in which certain muscles are disengaged; those that make up chains in the human system (i.e. left AIC, Right BC, right TMCC). It is neutrality that allows us to function out of an unbiased non-lateralized position.

We will never be fully symmetrical because we are neither built as such nor function cortically as such. But being able to be as symmetrical as possible may allow our bodies to function favorably.

Achieving neutrality is only step one in the process. It allows for someone to accept triplanar movement. Once one can reach neutral, then you may teach them how to move with the left and right sides of the body.

Is it possible to be too neutral? The answer is it depends. Mike Cantrell, one of PRI’s instructors, discussed a sprinter he was treating. Mike was able to get him neutral, but once this occurred his times worsened. This result goes back to part 1’s discussion regarding variability. In this case, being neutral, being too parasympathetic, made him slower. We could akin this to almost parasympathetic overtraining.

The crazy thing? This sprinter’s sister had died earlier in a week he was scheduled to see Mike. The guy came in as neutral as could be. His nervous system shifted him towards this state as a way to disengage, thus leading him to difficulty reengaging the requisite sympathetic tone needed for sprinting.

As we can see, there are multiple influences present that can affect one’s body position. Whatever inputs that your nervous system receives will influence system outputs. It could be nociception from a facet, your foot contacting the ground, an altered visual system…

“Or maybe, maybe, maybe, you need a new wife” ~Ron Hruska

PEC-Speak

We talked a little bit about PEC-patterns, which Ron likes to now call bilaterals. This nomenclature means that both sides are relatively symmetrical positionally. When talking about these individuals, much discussion revolves around the pelvic inlet and outlet. But I will save that talk for next month once I attend pelvis 🙂

We also discussed a little bit more regarding the nebulous Hruska adduction lift test with this clientele. And basically, someone who presents with a PEC pattern may not be able to truly alternate until they score 2/5 (bottom-leg can internally rotate) on either side. Any score lower and the low back will likely compensate.

We are Some Families

We spent a great deal of the day discussing the different planar PRI families, which when combined beautifully illustrate the systematic approach this organization utilizes. Here are the families that we go after in order:

  1. Sagittal plane (stoplight – help turn off chains): left hamstring, right iliacus, right lower trapezius/tricep, right rectus capitis posterior and obliquus capitis superior, right rectus femoris and sartorius
  2. Frontal plane adduction (the organizer – puts us into the opposing chain): Left IC adductor, right psoas major/minor, right serratus anterior, left iliacus
  3. Frontal plane abduction (the strength builder): right obturator internus & externus, right abductor/glute med, right upper trapezius, right rectus capitis lateralis, right SCM, left obturator internus and iliococcygeus
  4. Transverse plane (Does the work): Right pec major, left pleura, right glute max, left middle trap, right rectus capitis posterior major, Right obliquus capitis inferior and superior, Left lateral pterygoid, Left SCM, left gluteus medius
  5. Internal rotation (closes the deal to triplanar function): anterior left glute med, left iliacus, right subscapularis, left serratus anterior, left anterior temporalis, left lateral pterygoid, posterior right glute max, right piriformis, coccygeus, and inferior glute max.
  6. Integration (opposition maintainers):  Left transversus thoracis, left abdominals

So the activities that we learn in the basic courses are really just taking pieces of these families to progress movement. These activities are well and good no doubt, but ultimately we want to utilize as many of these muscles as possible.

Take the sagittal plane for example. In the Myokinematic Restoration course we learned specific activities to turn on the left hamstring. Here we only have one sensory input in the family helping us achieve our goal. In more advanced courses, we would perform activities that incorporate many, if not all the muscles in the sagittal family. Progressing in this fashion significantly increases the amount of sagittal input that the brain receives. Summating this input may compel the brain to respond in some way, hopefully quieting down overactive muscle chains and facilitating triplanar movement.

(In)Famous Ron Quotes

  • “You can’t stand on both feet. If you could you’d be a corpse.”
  • “Do you want GERD? Do I want GERD? I don’t want that.”
  • “I kinda think Lady Gaga is cool sometimes. I dressed up.”
  • “Physiological is psychological.”
  • “It is impossible to have a neutral spine. It’s constantly in fluctuation.”
  • “Everything you bring to your body is either used or expelled.”
  • “Every time I see a high heel I worry about their enamel.”
  • “They’re [people in high heels] oral butt clenchers.”
  • “Abduction is Lady Gaga.”

Cantrellisms

  • “If we can make you worse, we can make you better.”
  • I won’t put some of his famous similes, namely because I can’t remember the context and may steal some of his magic 🙂
He was born that way...But he wasn't born that way.
He was born that way…But he wasn’t born that way.

Course Notes: Advanced Integration Day 1 (Synchronous Breathing)

Mind Blown

My mind is still racing from PRI’s annual Advanced Integration course. It is over these four days that we linked all the chains learned in the basic courses into one interdependent system. As I have not taken all the PRI courses yet, I was very fortunate to have Bill Hartman, Doug Kechijian, and Young Matt to help me through the rough patches.

Courses are so much more enriching when taken with friends.

There was way too much material covered over the four days to write in one post. So here is the first of a four part series on this excellent class. Read on.

 Autonomics and the ZOA

The first day’s primary objective was establishing a zone of apposition (ZOA), the diaphragm’s cylindrical aspect that lies along the chest wall. Establishing this zone is of utmost importance, as it allows for favorable respiration.

You know I have a good zone of apposition, do you?
You know I have a good zone of apposition, do you?

Respiration influences movement by allowing better change of direction and variability. If I establish and maintain a ZOA, then I can effortlessly maximize movement in all three planes.  When I cannot perform in this way, then I have less triplanar activity when I move.

When one does not establish a ZOA, one must greater rely on the autonomic nervous system (ANS). Depending on what your goal is, this shift can be well and good. Take an example I got from Bill and my friend Eric Oetter. A sprinter or powerlifter who moves in one direction would not like much variability in how they move, thus triplanar activity in their sport could be disadvantageous. Conversely, a basketball player or dancer needs to be able to move in multiple planes in unpredictable fashions. These athletes may benefit more from being successful movers in multiple planes.

Now if only the airports in Nebraska were more successful at moving multiple planes.
Now if only the airports in Nebraska were more successful at moving multiple planes.

If you fall too far in one direction of the ANS, problems may rise. Too far sympathetic, and you can never shut down and rest. Too far parasympathetic and you cannot power up when you need to.

The ultimate goal is to be off when you need to be off and on when you need to be on.

The reasons above are why PRI emphasizes flexion so much. When I have the ability to flex, I have greater variability to change. In extension, movement blocks more likely occur. If you think about the human body, how many joint’s closed packed positions involve extension? Answer: the entire spine, the hip, the knee, and most of the elbow and wrist that I can think of. If we look at the spine in particular as the governor of how much the appendicular skeleton moves, one relying on too much extension will not be able to utilize any other planar motion.

I want to flex myself out of an extended sympathetic state to ensure movement freedom. The way I can achieve variability, achieve function, is through breathing. Breathing is what allows us to less rely on structural closed packed positions for movement, and function favorably in a triplanar fashion.

Don't let them take your freedom...of movement.
Don’t let them take your freedom…of movement.

The Human Chain

The human body is composed predominately of chambers. These chambers regulate change. But in order to change, one must be asymmetrical.  In gait for example, if I were completely symmetrical I would have to hop to walk. Thus, movement has to start within an anatomical asymmetrical position. Asymmetry is good and normal. And if someone is completely symmetrical (a PEC per PRI terminology), some asymmetry must be introduced.

The human chain, the human system, is composed of two alternating reciprocal sides; a left and a right. If talking sagittal plane alone, the chains look as below.

Yes, my artistic services are for sale.
Yes, my artistic services are for sale.

In an asymmetrical human being, each chain is reciprocal because the chains can reverse position. For example, the extended pelvis on the right can flex, the flexed cranium on the left can extend, etc. The ability to alternate means that you can seamlessly switch activity between the left and right side.

Oftentimes in PRI, we talk about the concept of neutrality. Neutrality is only the midpoint between these two chains. It is a prerequisite to allowing alternation between the left and right side. Neutrality is not the goal unless you are not moving. It is merely the gate that allows you to move from the left and the right.

Septums

Setpa are what separate chambers, like a partition. These septa allow for oscillation within chambers and give you internal structure.

These septa and chambers are present structurally secondarily to internal organs. For example, the reason the right diaphragm is larger than the left is because the liver is located directly below the right.

Because the organs create these structures, they must also structure planes of motion within chambers. Muscles are present to mobilize these chambers via the planes. And when a plane of motion is lost, your body twists and torques septa to increase support. This planar loss is part of the reason why the PRI patterns are the way they are.

Septa are found throughout the body, but the most obvious example is the septum transversum; more commonly known as the diaphragm. The diaphragm is was separates the thoracic and abdominal chambers, and allows for oscillation between these chambers.

There are several diaphragms throughout the body, and it is here we must establish ZOAs. The big three ZOAs that need to be established involve three chambers: the pelvis, the thorax, and the cranium; aka the snow man.

The only use I have for winter.
The only use I have for winter weather.

These multiple target areas posit the question: which to prioritize first? And basic rule to neutrality involves establishing the pelvis, then the thorax, and lastly the cranium. If one cannot be established after getting others, then that is the one you must go after. Your PRI testing will help you figure out where you need to go.

Establishing ZOA

A ZOA can be achieved predominately by pausing after an exhale. Oftentimes, forced exhalation is utilized to create a zone, but hard expiration is not necessary. All an exhale needs to be able to do is flex, adduct, and internally rotated on the left so a ZOA is achieved via internal obliques and transversus abdominis.

Once you achieve and maintain a ZOA, just breathe and move.

Breathe, move, then get out the way.
Breathe, move, then get out the way.

There are several factors that go into with or not a ZOA can be established and maintained. When designing a program, ZOA establishment can be affected by the following:

  1. Left abdominal obliques and transversus abdominis
  2. Left acetabulofemoral internal rotation position.
  3. Neutral temporal fossa position
  4. Right medial longitudinal arch support
  5. Adequate left femoral, right humeral, and left temporal internal rotation.
  6. Neuromuscular reciprocal alternating activity on the sacrum, sternum, and sphenoid.
  7. Full left humeroglenoid flexion and horizontal abduction.
  8. Left posterior mediastinal expansion.
  9. Left pelvic inlet extension

Thus, the aforementioned movements ought to be trained and integrated into alternating reciprocal activity we call gait.

(In)famous Ron Quotes

  • “Think System”
  • “Before you can move you have to learn how to stop.”
  • “I wish I went to a school that said you need your abdominals to poop.”
  • “It’s all about wiring [the nervous system]”
  • “I, Ron Hruska, love asymmetry. Please tweet that.”
  • “If your spine is unstable, thank the good Lord. We want mobile spines.”
  • “The neck runs the show and is often the most difficult place to change.”
  • “Blow that balloon up to express yourself.”
  • “I see a lot of x (e.g back pain), but I don’t see a lot of x.”
  • “The right diaphragm is saying I got your back….Literally.”

Stay tuned for day 2.

Different level brilliant, and loves his bumper stickers :)
Different level brilliant, and loves his bumper stickers 🙂