I had learned so much about what they do in PRI vision that I was feeling somewhat okay with implementation.
Then my friends told me about the updates they made in this course.
I signed up as quickly as possibly, and am glad I did. This course has reached a near-perfect flow and the challenging material is much more digestible.
Don’t expect to know the what’s and how’s of Ron and Heidi’s operation. And realistically, you probably don’t need to.
Your job as a clinician is to take advantage of what the visual system can do, implement that into a movement program, and refer out as needed. This blog will try to explain the connection between these two systems.
If you want more of the nitty-gritty programming, I strongly recommend reading my first round with this course. Otherwise, you might be a little lost.
Note: I made some errors on the first rendition of this blog that were corrected after speaking with Eric Oetter. Courtesy to him, Lori Thomsen, and Ron Hruska for cleaning up some concepts.
Four Months Later
When the Lori Thomsen says to come to Cervical Revolution, you kinda have to listen.
I was slightly hesitant to attend since I had taken this course back in January. I mean, it was only the 3rd course rendition. How much could have changed?
Holy schnikes! It is simply amazing what four months of polishing can do. It was as though I attended a completely different course. Did I get it all figured out? No. But the clarity gained this weekend left me feeling a lot better about this very complex material.
This is a course that will only continue to get better with time; if you have a chance to attend please do.
Let’s now have a moment of clarity.
The craniocervical region is the most mobile section of the vertebral column.
This mobility allows regional sensorimotor receptors to provide the brain accurate information on occipital position and movement.
The neck moves with particular biomechanics. Fryette’s laws suggest that the cervical spine produces ipsilateral spinal coupling in rotation and sidebending. The OA joint, on the other hand, couples contralaterally.
C2 is the regulator of cervical spine motion; much like the first rib regulates rib cage movement.
C2 is also important for the mandible, as it balances the cervical spine during mandibular opening. The reason this occurs is because the mandible and C2 are at the same fulcrum level.
Often triplanar motion will decrease amidst progressive respiratory demand or threat. These changes help promote neck stability while simultaneously increasing demand on the mandibular elevators, extraocular muscles, and vestibular system
If these changes occurs long enough, sensory issues may become prominent.
Stability can occur through increased sagittal plane activity in the upper cervical spine and cranium either one of two ways:
O on A via posterior cranial rotation
A on O via forward head posture
Both strategies attempt to flex the cranium, but both are undesirable if occurring underneath a lost cervical lordosis.
OA hyperflexion is often seen in those who sit in front of monitors for long periods of time. The visual system helps promote stability.
OA Hyperextension is an attempt to create an airway. Cranial protrusion may be utilized as a way to open up the airway under stable conditions. This position passively raises the hyoid bone, which often depresses when one uses a mouth-breathing strategy. These individuals rely heavily on the dentition for craniocervical awareness.
Of course, these are not the only ways undesirable neck stability can occur.
You might have a stable neck if:
You have a narrow palate.
You have a cross bite.
You have a narrow airway.
Patterned Mechanics 3037
The TMCC is the foundational polyarticular muscle chain at the neck, with the right side generally more active than the left.
The normal RTMCC pattern presents with the following at the neck:
C2-C7 orientation in the transverse and frontal plane to the right, with compensatory rotation and sidebending to the left.
The OA joint is sidebent to the right and rotated left as a passive orientation.
The RTMCC may be present in isolation or with various cranial strains.
A cranial strain may occur if the left SCM sidebends the OA left within the RTMCC pattern. This compensatory movement occurs to attempt to reduce OA rotation and upper cervical strain.
If you weren’t sleeping during the biomechanics section, you will notice that this goes against Fryette’s laws. In order for this compensatory strategy to occur, the right alar ligament and posterior capitis muscle must become lax. This movement does help reduce torsion and compression on the upper cervical segments, but may create a cranial lesion in the process.
This compensatory movement is a precursor to a left sidebending cranial lesion, and this lesion along with others are quite prominent.
According to a 2008 study by Timoshkin and Sandhouse, 72% of individuals have a cranium that is in a sidebend or torsion pattern; with left sidebend and right torsion being the most common.
Of those two cranial strains, the left sidebend will be the most common. Let’s dive into that pattern more.
Left sidebend (LSB)
The LSB lesion is named for the sphenoid’s greater wing position. In this case, the greater wing is high on the right and low on the left. The occiput matches this orientation.
Where these bones will differ occurs about a vertical axis; as the sphenoid externally rotates while the occiput internally rotates.
The mechanical change at the atlas drives this position. The sphenoid just goes along for the ride.
A prime example of this cranial strain would be the lovely Garey Busey.
Right Torsion (RT)
RT’s also have a low left greater wing of the sphenoid, but the big difference is at the sphenobasilar joint.
Since the RT is a progression from the LSB, the occiput will attempt to sidebend right to level occipital position. Since the sphenoid stays in position, torsion through the sphenobasilar joint occurs.
This twist is driven by the sphenoid as means to create pseudo-facial symmetry via extension.
Lorimer Moseley is actually a perfect example of this type of cranial position, as many facial features are flipped from a LSB face.
This is a Test
The only way to truly determine which cranial strain one has is through imaging, but PRI testing can guide us down a treatment path.
Admittedly, the cervical tests are not the most reliable of the PRI bunch. To attempt to offset this limitation, we shall imply a test battery to determine position.
There are four essential tests in the TMCC algorithm:
Cervical extension: Checks cervical lordosis presence; goal is 30-35 degrees.
If limitations are present it is likely that SCM hyperactivity is reducing the normal lordotic curve.
I think of this test as the extension drop test of the cranium. It tells you if you are working with someone who is sagittally lax or not.
Cervical axial rotation: Checking C7-T1 rotation, which reflects C2 position. Looking for symmetry at about 30-35 degrees of movement. This test determines the TMCC pattern.
Limitations will be present due to the cervical spine’s compensatory rotation and sidebend to the left. Placing the patient supine on a table rotates the spine further to the left, which places a RTMCC patterned neck in an end-range position. Hence, normally left cervical axial rotation is limited. We would see bilateral limitations in a BTMCC.
When performing this test you want to make sure that you do not give the patient a lordosis, for this can create false negatives.
Midcervical sidebending: I think of this test as the great comparer between the cervical spine and the cranium. Looking for symmetry at about 30-35 degrees. This test gives you a frame of reference for our next test.
In the RTMCC pattern, this test is limited to the right secondary to an arthrokinematic block. If the cervical spine is rotated left on the table, the neck cannot sidebend to the right. That’s Fryette’s laws brah!
OA sidebending: This test looks at cranial position. Looking for 8-10 degrees bilaterally.
More than 10 degrees of sidebending would indicate alar ligamentous laxity.
A RTMCC individual would have limited right OA sidebending due to a bony block. In someone with a LSB however, you would have limited L OA sidebending because the left SCM pulls the OA over to the left. A RT could present with just about anything, as pathology is quite prominent in these folks.
RTMCC repositioning and retraining goes about the following progression:
Cervical spine → OA joint → Mandible
The neck is the top priority because its mobility maximizes cranial sensory activity.
Moreover, most cranial activities are integrated multi-joint movements. Spending time doing “basic” PRI sets the foundation for one to combine complex movements.
Mandibular movement is often normalized by the time the neck is cleared. The reason TMJ mobility may be limited because of craniomandibular discord.
In the RTMCC pattern, the right lateral pterygoid works with the right anterior capitis and right SCM to deviate the temporal bone and mandible to the left whilst the occiput (and sphenoid) are “stuck” in the left sidebend position. In a neutral system, we would expect the occiput and sphenoid to move to the right during this cranial movement. This tonal issue could limit mandibular movement.
Thus, a neutral cranium often restores normal TMJ mechanics. If problems still arise, then mandibular re-education may be necessary.
Sometimes you need a Dentist
Of the two common cranial strains, RTs will most likely need integration.
With normal occlusion, one side of teeth should touch while the other discludes. This alternation creates lateral shifting in both the mandible and the cranium.
The canine teeth act as guides for where the jaw ought to be in space. When canines touch during shifting, molar contact follows as the teeth drop into position. This action is called group function.
If group function cannot occur, it is likely that a dentist may need to be involved.
Splint therapy is generally recommended in these cases. More specifically, mandibular splints are the go-to (which I spoke about here and here).
Maxillary splints are generally the devil. These splints tend to increase tongue activity and mandibular clenching to hold the splint in. The one major case that may warrant a maxillary splint is the presence of tori.
Even if not using PRI splints, there are four essential pieces needed from a dentist:
Don’t lock the mouth into a position.
Move head back and jaw forward with canines.
Feel one side occlude while the other side discludes.
Have group function and anterior guidance between incisors.
Note – anterior guidance is when the incisors touch the molars disclude
You might be wondering how I educate people about this stuff in a nonthreatening fashion. I got this neat little tidbit from the Ronimal:
“Periodontal ligaments are so sensitive that a hair will throw off your gait.” ~ Ron Hruska
Think about that statement the next time you get something stuck in your teeth. Drives you crazy right? If there is something undesirable going on with your teeth, you will know about it in some way. Some output will occur.
Moreover, think about what occurs at the dentition when stressed. Do you clench? Reducing this muscle over activity by splint therapy introduces a salient stimulus that could reduce the stress response, if the craniocervical region is involved.
Hint: It usually is.
Infamous Ron Quotes
“Every single bunion and ACL patient is a TMD patient.”
“I love dentistry, but I don’t like dentistry, but I like dentistry.”
“You cannot treat a neck if a neck can’t treat itself.”
“We are a product of how we move our cranium.”
“A bra strap will really mess a tongue up.”
“The worst thing you can do to a patient is splint their neck.”
“We still have a lot of goniometric minds.”
“What good is the polyvagal theory if you don’t understand the neck.”
“Don Neumann is the best book for 1% of the population.”
“Treatment starts when you appreciate frontal plane.”
“How can you treat a TMJ if you can’t control the T?”
“The vehicle you drive is not the problem, it’s the path your on.”
“A twisted levator is an untwisted neck.”
“Hallelujah you have a pattern.”
“When you lose your left ab wall the head and neck will pick up the slack.”
“You can learn a lot about cognition and personality if you look at a neck.”
“You can’t feel CSF flow if you lack a cervical lordosis.”
“Make sense out of sense.”
“A neck that can’t move will produce a cant.”
“Crossbites, pulled bicuspids, and high arches scare me.”
“Sedentary lifestyle and screens demand we go straight.”
Back in April I had the pleasure of finally attending PRI’s annual symposium, and what an excellent learning experience.
The theme this year was working with high-powered, extension-driven individuals.
The amount of interdisciplinary overlap in each presentation made for a seamless symposium. Common themes included the brain, stress response, HRV, resilience, and drive. These are things altered in individuals who are highly successful, but may come at a cost to body systems.
If you work with business owners, CEOs, high-level athletes and coaches, high level positions, straight-A students, special forces, and supermoms, this symposium was for you.
And let’s face it; we are both in this category!
There were so many pearls in each presentation that I wish I could write, but let’s view the course a-ha’s.
The Wise Words of Ron
Ron Hruska gave four excellent talks at this symposium regarding high performers and occlusion. Let’s dive into the master’s mind.
People, PRI does not think extension is bad. Extension is a gift that drives us to excel. Individuals who have high self-efficacy must often “over-extend” themselves. This drive often requires system extension.
Extension is a consequence, and probably a necessary adaptation, of success.
If this drive must be reduced to increase function and/or alter symptoms in these individuals, we have to turn down the volume knob.
How can we power down these individuals?
Limit alternate choices – These folks take a wide view of a task
Set boundaries – These folks attribute failure to external factors
Making initial tasks successful – So these folks don’t give up at early failures
Objectively measure improvement – This helps motivate people to continue
Establish rhythmic activity that reflects specific set goals – the higher the goals the more likely the positive change.
A Tale of Two Forward Heads
We discussed a lot of attaining neutrality at the OA joint. What does that entail?
A: Both occipital condyles centered in the atlas fossa with unrestricted lateral flexion.
What is needed to have that?
55-60 degrees of cervical extension.
Equal bilateral first rib rotation position.
Centric occlusion with the anterior teeth guiding protrusive movement and canines guiding lateral movement.
Normal maxillary and mandibular teeth contact.
Ability to nasal breathe.
Alternating pelvic capability.
Normal hearing bilaterally.
Lose any one of these and a forward head posture may occur.
The two types of FHP we see include one with the atlas migrating forward with increased cervical flexion and occipital protraction.
And one in which the atlas migrates backward on the occiput in which excessive upper cervical flexion coupled with lower cervical/upper thoracic hyperextension.
With the former’s case, these individuals have a harder time feeling posterior teeth; a loss of frontal plane. When one loses frontal plane, the individual must attempt to increase anterior guidance via extension. Strategies used to do this include tongue thrusting, bruxism, fingernail biting, mouth breathing, clenching, etc. These strategies are protective in nature as they limit potential stress at the TMJ and OA.
Most of the latter include your bilaterally extended individuals. They retrude the atlas to significantly increase cervical stability. This hyperstability allows for dominant performance in the sagittal plane. These individuals may need more visual interventions.
She’s a Wise Woman
Dr. Heidi Wise gave one of my favorite presentations of the symposium. She discussed vision’s role in extension-driven individuals.
Vision is the most dominant sensory modality, as it has the ability to override all other senses to redirect attention. To me, this is why vision is such a powerful way to get someone neutral.
Redirection of attention through the visual system occurs through saccades. These eye movements occur 85% of the time our eyes are being used. This is how the visual system detects a salient stimulus.
If visual processes hold someone in an extension pattern, it may become extremely difficult to near-impossible to overcome.
Here is how we start thinking a visual process may be promoting an extension pattern:
Those who cannot inhibit extension with traditional floor-up activity.
Late-onset (past puberty) or severe near-sightedness.
People with extremely good eyesight.
Folks who over-focus on objects straight ahead (people who stare).
People who walk with purpose (makes me think of my mom in the mall!).
If someone over focuses (read: nearsighted), eye exploration is minimized. It becomes much harder to notice change, or salience. This is how the visual system can keep someone stuck in a stress response.
What is needed to see close?
Increases in acetylcholine and norepinephrine.
Reflexive increase in neck/head muscle tension. More so if one must strain to see.
Do this too long, and we can see unfavorable autonomic, visual, and neuromuscular stress.
And guess what visual field research is showing we better attune to? The right side; more specifically, the right upper visual field.
The PRI goal? We want to restore ambient vision in these individuals to process three planes of visual motion.
Here were some of Heidi’s recommendations for how to do so.
Take breaks from a task to move.
Be aware of surroundings on both sides without looking when walking.
Walk slower than usual.
Look around using your eyes independent of your head.
If nearsighted, take glasses off occasionally and “be OK” with things far away being blurry. Don’t strain to see well.
Have top of computer screens at about eye level. Look far from the screen as often as possible.
Close eyes and visualize a large open area that makes you calm.
Minimize time on small, close screens and keep object far from eyes.
Read books over e-readers and keep the book as far away as visually comfortable.
Emphasize peripheral awareness before and after high attention tasks.
Change variable such as sounds or environment during high attention tasks.
Strongest memories are tied to emotions; more negative than positive.
If the limbic system is too active (such as in a threatening environment), prefrontal cortex activity goes way down. You can’t learn as well.
Cranial nerves are extremely important in social interaction. Nonverbal cues from these areas can unconsciously affect autonomics.
During adolescence (12-25) the right side of the brain and limbic system develop faster than the left and neocortex. This lateralization is why this time period can be so emotion-driven.
Face to face interaction is needed to cultivate the nervous system. This is the problem with social media and texting.
Dopamine pathways are very active during adolescence; it’s one of the reasons addictions start during this time.
Feelings of being overwhelmed are 6 times more common in those who have had concussions.
Rehearse making mistakes and how you will come out of them.
He also provided some great patient interaction nuggets that I hope to liberally steal.
Keep your eyes on the individual and tell them “it’s great to see you here.”
If you are not doing well on a given day – “I don’t feel good today but we’re going to have a good session.”
If you are at odds with a patient – “We’ve seemed to come to a roadblock. Would you agree?”
My big takeaway from psychologist Dr. Tracy Heller’s talk was mindfulness.
Mindfulness is something I am hoping to get more into in the future. She defines it as being aware of your thoughts, emotions, physical sensations, and actions in the present moment without judging or criticizing yourself or your experience.
It’s a big deal to have this capability. Practicing mindfulness has been shown to reduced cortisol, stress, pain, depression, and anxiety; while also improving memory, sleep, and cognitive function.
The way we build mindfulness is basically letting go. I like the analogy that I heard while using Headspace (a great app if you haven’t used it). Imagine your thoughts and feelings as cars in traffic. Your goal is to just watch the cars pass by, not chase them. You want to be present in the moment, as we want in most of life.
One option of practicing this is resonant frequency breathing, in which we perform 4.5-7 breath cycles per minute. Let the body breathe on it’s own and let the air come in; using terms such as “let,” “allow,” and “permit.” These are cues I have been using much more with patients and has made a big difference.
This was easily my favorite part of the symposium (I may be biased since my Dad gave this talk). Bill Hartman blew it out of the park teaching us how PRI applies at the highest level of performance.
The rules change in the performance realm because the patterns are incredibly powerful, effective, and efficient. In some cases we may want them. A perfect example that Bill gave: Usain Bolt
Rarely does he cross midline when he runs, making him the fastest runner on one leg. Do we want to change that? Probably not.
Performance does not equal health. Gymnasts for example, may need to create pathology to perform at a high level. Some people must utilize passive elements to produce greater outcomes. Usain Bolt runs on one leg. Everyone is a case-by-case basis. N=1 forever.
What must occur in the performance and health realm is stress management. Acute stressors with recovery make us antifragile; prolonged stressors reduce variability as an allostatic adaptation.
If one must constantly perform at a very high level, where will they be on this stress dichotomy? Prolonged stressors = reduced variability, sympathetic dominance, and system extension.
Variability helps us anticipate demand. It helps us become better able to cope with specific environments and recover movement function. The only way we can know if movement variability is present is through assessing the musculoskeletal system
“The state of the musculoskeletal system is the other end of the brain” ~ Bill Hartman
If stressed or threatened, body systems use default reflexive mechanisms to combat threat. The brainstem is much faster than the cortex. As a consequence, variability can be lost.
Attaining increased prefrontal cortex activity allows us to inhibit our default response and increase variability. That’s why mindfulness increases HRV, and that’s why a 90/90 hip lift can alter body position.
To better manage stress, we must train. Training is a progressive desensitization of threatening input to allow an athlete to perform at adaptive potential with optimal variability and without fatigue.
The higher performance level required, the more difficult it becomes to get neutral. This is what happens during functional overreaching. You gain higher performance output during this timeframe because the sympathetic nervous system and HPA axis are on overdrive.
Applying Bill’s principles along the training and rehab continuum, rehab requires neutrality and variability to rebuild a failed stress tolerance. The amount needed in performance realm will depend on how (in)variant one’s sport is.
The Wild World of Combat
Dallas Wood and Zach Nott work with in a military population, and it was fascinating showing how they mitigate the extension necessary for their clientele to perform. They guys collect a lot of data, and the fun factoid was that about 80-90% of their individuals are PEC and bilateral BC (surprise surprise).
They showed us a very cool auditory case. They had a dude with a PEC/BBC presentation with a history of ear trauma and tinnitus. When they blocked his left ear the gentleman was completely neutral.
Treatment underwent reducing the tinnitus by implementing a hearing aid that uses various white/pink noises to slowly reduce tinnitus. Not sure exactly how it works, but this was exciting to hear about (ha). I look forward to learning where PRI takes auditory integration.
So there you have it. I already signed up for next year’s symposium because this one was so much fun. I look forward to more of the consistently fantastic content that PRI provides. Learn on!
You know how sometimes when you are treating someone that individual eventually reveals fairly important information that he or she forgot about.
Yeah that was totally me.
I’ve always had a stuffy nose as far back as I can remember; especially in the winter. The only time breathing felt incredibly easy was when I was eating paleo in college. I have progressively been losing my sense of smell as well.
Must be old age right?
When I spoke with Lori Thomsen about my recent experience, she mentioned at Pelvis that attaining neutrality in certain areas but not others could lead to a “pressure cooker” phenomenon. For example, if I have someone with a neutral neck and thorax, lower extremity symptoms may possibly be more common.
In my case, I had a neutral pelvis at the time my wisdom teeth were pulled. Pull out wisdom teeth and my nasal airway goes crazy. Guess where the pressure went?
It was time to see an ENT.
After viewing my CT scan and airway, my ENT concluded I have patho-scoliosis.
More specifically, airway scoliosis. He found a deviated septum and some enlarged turbinates. These two factors could have a large impact on my breathing capabilities.
To me this made a lot of sense. If you read this article, a nostril will drive air to the ipsilateral lung. So depending on what nasal airway is blocked may dictate whether I am a Right BC or a superior T4.
Moreover, sensory information through the nose travels to the contralateral hemisphere. In my case, my left airway is a bit more open than my right, which would increase sensory input to my right hemisphere.
Per the RTMCC pattern, I actually should have a more open right airway. So this finding would be considered patho per PRI standards. Hence the pathoscoliosis.
Could this abnormality be a contributing factor as to why I am solid on my left side but struggle when I go back to my right? Or even why I’m left-handed? Purely theoretical of course, but something I play around with in my head. I think weird shit like that.
Surgery is not the first line of defense, so we started with conservative measures. I was given a nasal saline rinse and couple nasal sprays to reduce inflammation and symptoms.
Let me tell you, I could notice a difference with the first rinse.
The very first nasal rinse treatment opened up a whole new world for me. I cleaned out the sinuses and immediately measured my horizontal abduction:
20 degrees to 45.
I think I found a new repositioning technique.
The coolest thing? I could smell again. It’s amazing the scents in my apartment and the clinic that I could now pickup that I never noticed before. It was an incredibly rich sensory experience. Sleep quality drastically improved within the first couple nights as well.
The only downside was the effects were not long lasting. It was time for phase two.
Nasal Adductor Pullback
About a month later I went back to the ENT and had an allergy test.
The good news is that I am not allergic to any foods. I can eat anything I want (yay). And actually I didn’t have many allergies at all.
The bad news is that I have a large allergy to perennial rye grass, which is extremely common in AZ. I also have a couple allergies to a few other weeds or molds, but nothing major.
The next step is to try immunotherapy to see if I can reduce my sensitivity to these allergens. This basically amounts to me taking oral drops for the next three years. The hope would be that the threat these allergens are to my system would become nonexistent.
I ought to notice some changes over the next 6 months. If not much symptom-wise is changing, surgery to reduce the turbinates and align the septum will be the likely next step.
If only I could tell the ENT that my symptom was limited cervical axial rotation.
Lori is a very good friend of mine, and we happened to have two of our mentees at the course as well. Needless to say it was a fun family get-together.
Lori was absolutely on fire this weekend clearing up concepts for me and she aptly applied the PRI principles on multiple levels. She has a very systematic approach to the course, and is a great person to learn from, especially if you are a PRI noob.
Here were some of the big concepts I shall reflect on. If you want the entire course lowdown, read the first time I took the course here.
Extension = Closing Multiple Systems
This right here is for you nerve heads.
It turns out the pelvis is an incredibly neurologically rich area.
What happens if a drive my pelvis into a position of extension for a prolonged period of time?
I’ve written a lot about how Shacklock teaches closing and opening dysfunctions with the nervous system. An extended position here over time would increase tension brought along the pelvic nerves. Increased tension = decreased bloodflow = sensitivity.
We can’t just limit it to nerves however, the same would occur in the vasculature and lymphatic system. We get stagnation of many vessels.
Perhaps we need to think of extension as system closure; a system closing problem. Flexion will be the solution to open the system.
Pausing after an exhalation gives diaphragms time to ascend. Diaphragmatic ascension maximizes the zone of apposition (ZOA). The better ZOA we have, the less accessory musculature needed to take an adequate breath.
The two important ZOAs needed in this course are at the thoracic and pelvic diaphragms. We want to build synchronicity between these two diaphragms.
The way we do that is through the pelvic inlet.
The inlet links and adequately positions these two diaphragms via internal obliques and transversus abdominis (IO/TA).
To determine how this occurs, we must look at how breathing affects musculature.
This part here was a huge lightbulb moment for me. Muscle lengthening correlates with inhalation, and muscle shortening correlates with exhalation. So to create a stretch in areas you wish to lengthen, you may want to inhale, and to increase muscle contractility, you may with to exhale.
[Note: This is one reason in lifting exhalation is during the concentric phase and inhalation is during the eccentric phase?]
Now lets apply this concept to the pelvic inlet in an extended system. Let’s say the left innominate is forward (a LAIC pattern). My left IO/TA on would be eccentrically lengthened and in a state of inhalation. The left thoracic and pelvic diaphragms would be tonically active and form a v-shape.
This dyssynchrony explains why certain pelvic and thoracic tests correlate. The LAIC pattern suggests that I would not be able to adduct my left hip.
At the pelvis, this would occur because I have a “long” left anterior outlet and “short” posterior outlet.
The outlet and the thorax reflect one another. In this case, my anterior outlet is equivalent to the ipsilateral anterior chest wall and my posterior outlet is equivalent to the posterior mediastinum.
Guess what the tests will look like? I will have good left apical expansion and limited left posterior mediastinum expansion. I can’t adduct my left thorax or abduct my right thorax, much like I can’t adduct my left hip or abduct my right hip. These tests look at the same thing the pelvic tests do.
The Definitive Word on PRI Squatting
We can look at one’s ability to actively synchronize the thoracic and pelvic diaphragms by one’s ability to squat.
The functional squat test is an excellent way to show if one is capable of maximal pelvic diaphragm ascension and can shut off extensor tone. It also is a test to see if one has a patho-compensatory pelvic floor; for if you can squat but can’t adduct your hips, you gotz problems.
Here is what the functional squat test is not: a position to go under load in the weight room.
The above was straight out of Lori’s mouth. So to all the people who talk smack about the PRI squat, your answer is above. It’s not looking at the same thing as a max effort back squat.
Here’s how to test it.
Sitting is Hahhhd
In PRI land, sitting is the most challenging position to be in.
Why? Because there are less points which one can reference. Sitting unsupported requires proprioception exclusively on your ischial tuberosities. Success here relies on alternating and reciprocal muscle recruitment. If I don’t have this, I will extend.
Some Quick Postural Eyes
Lori is a great at predicting how dynamic movements will look on the table. Here were a couple things that stood out to me in this regard, as well as a couple other random things.
Leg whipping means an individual likely has a femur stuck in adduction.
Patho-compensatory people usually have more narrow hips. Could possibly be more common in males for this reason.
People who lean to one side in gait need a glute med.
If one cramps during an exercise, think inhibition. We’d rather shaking.
Glute med is the needed ligamentous muscle if a hip subluxes laterally.
Furniture is made to fit people who are 5’8.
Hard orthotics = overrated. We want a soft heel cup and arch to be used proprioceptively.
“I like to refer to myself as your coach.”
“You can’t work the same muscle in a different position and expect the same outcome.”
“You know I’m going to have to spend some time on this little booger.”
“If you want to give more pelvic instability stretch hamstrings.”
“She trusts me and I make her shake which is all good.”
“PECs cannot breathe to the high moon.”
“Getting neutral is not treatment.”
“Her back needs to go on a holiday.”
“Run with ribs.”
“When you go run, run.”
“We like extension, just not 24 hours a day 7 days a week.”
“If your patients cannot breathe correctly, don’t do a PRI activity. They will fail.”
“Not everyone needs a pair of glasses. Some people need a diaphragm.”
“I’m not a comedian. I’m here to teach you.”
“We’re [the clinician] not in control. We’re just invited to the party.”
“I get excited when I feel my right glute max burn.”
“You gotta get those wisdom teeth pulled.” ~Ron Hruska
By virtue of the dentist I integrate with, the time came. And here are the results.
Zac B.E. (Before Extraction)
So at this point in my life the large HRV gains I initially had were dropping and I was still having some neck tension. Training was feeling so-so.
Test-wise, the videos below show what I look like.
Here’s my squat
And my toe touch.
Upper quadrant tests
And lower quadrant tests
And some cervical movements
My pelvis is consistently neutral and I can shift and squat with the best of ‘em. But I still present with restrictions in my thorax, neck, and mandible (BBC/RTMCC).
These limitations are likely present because of a bony block called wisdom teeth.
As you can see, the maxillary (top side) wisdom teeth limit the excurision of my lateral pterygoids for lateral trusive movements. My hope is by removing these guys I will get access to more frontal plane, which should clean, up my remaining tests.
Operation Extraction: 1/30/15
I enter the room to get prepped for surgery, and the worst possible thing occurs.
Country music is playing.
And I can’t have that!
So I politely ask one of the workers there if we can play something a bit more soothing prior to my surgery.
2pac “I ain’t Mad at Cha” begins playing.
That’s more like it.
I get the IV put in, hear some Juicy by Biggy, and pass out from the Mind Eraser anesthesia. Yes, it was actually called “Mind Eraser”, and yes, I remember nothing.
Like this happening
And definitely not this
But I do remember looking like Marlon Brando for a period of time
What was really cool about the whole experience is how little pain I felt. I probably took 2-3 pain pills at most. I think this is because I was actually excited about having this surgery done, and the reward I was hoping to get far exceeded the nociceptive information I would inevitably receive.
Just goes to show it’s all about threat perception.
Zac A.E. (After Extraction)
I waited to re-measure and assess until 6 weeks later. This way I had to some time to heal and adjust to this new sensory experience. My exercise program basically consisted of squatting, alteranting activity, and mandibular lateral trusion to feel my pterygoids.
The cons are I no longer looking like Marlon Brando, but the pro’s are the mobility gains. Check it out in the vids below.
Here are the standing tests
My upper quadrant tests
Lower quadrant tests
Here are my mandibular movements
And lastly, cervical
Since surgery I’ve been hovering between a right BC and superior T4. I consider myself no longer a TMCC patient because mandibular movement is now fully restored. The thorax position can limit cervical axial rotation.
In terms of how I feel, neck tension has been significantly reduced, especially with jaw movement. The only time I get the tension is when I am training hard or if I am reading/sitting for a real long time.
I also produce a crap-ton more saliva, which comes back to the very first question Ron asked me when I started this process. You don’t know what this stuff will affect.
Consequently, I have noticeably much more phlegm in my saliva and feel way more congested than ever. Sleep quality does not seem as good, as I have generally felt a bit more tired throughout the day.
So what gives? My thought was the wisdom teeth would be the final piece of my PRI quest, but I did not get all the changes I was hoping to get. Was Ron wrong? Did I get less wise for nothing?
The one consistent thing that I am still limited in is the cervical rotation and shoulder horizontal abduction. I am hesitant to perform any pec inhibitory activities because I have been neutral in the past. I don’t want to “stretch” something that doesn’t need stretching.
I look over my 3D CT scan that I got at the dentist office, and one thing stands out. I find my limiting factor:
Note from Zac: This is my first guest post, and to start things up is the one and only Trevor Rappa. Trevor was my intern for the past 9 weeks and he absolutely killed it. Here is his story.
It’s very exciting for me to get to write a guest post for Zac’s blog that I have read so many times and learned so much from. The experience I have had with him over these past 9 weeks has been incredible and I hope to share some of it with all of you that read this.
He challenged me to think critically in every aspect of patient interaction: how I first greet them, which side of them I sit on, the words I use, and how I explain to the patient why I chose the exercises they’ll go home with. All of this was to create a non-threatening environment to help to patient achieve the best results they can.
He also taught me how to educate patients with a TNE approach, incorporate other interventions such as mirror therapy into a PRI based treatment model, and deepened my understanding of the neurologic concepts behind performance.
Therapeutic Neuroscience Education
Perception of threat can lead to a painful experience which will cause a change in behavior. It’s the PT’s role to introduce a salient stimulus to attenuate the perception of threat in order to cause a positive change in experience and behavior (Zac and I came up with that, I really like it).
Pain is not the enemy. Teaching patients that their pain is normal and it doesn’t always mean that they are damaging themselves can be challenging as pain is often the reason patients seek out or are referred to PT. Some of the points we tried to teach patients were
Pain is there to keep you safe, which is good
Pain does not equal tissue injury
No pain, no gain is not what we’re looking for
Discomfort is okay
Knock on the door of pain, don’t try to kick it down
A large part of educating patients is helping them re-conceptualize why they are having pain. Most patients think of pain in terms of a pathoanatomical model (ie tissue abnormality=pain) and this is perpetuated by a lot of members in the medical community. The pathoanatomical language often causes a higher perception of threat and induces greater feelings of being broken, hopeless, and unfixable.
Re-educating the patients that what they are experiencing is normal and teaching them why it is normal helps decrease their perception of threat. We do not want to use language that will make patients more threatened, like telling a 20 year old that they have the spine of an 80 year old (numerous times our patients have been told that by other medical professionals). Getting them out of a mindset that if they move a “faulty tissue” they will make their situation worse is one step in this process.
Regardless of whether the patient is dealing with a more acute injury or one that has become chronic, there are three things we taught each patient that we would do in PT to help decrease some of the sensitivity they may be dealing with. Those three things are movement, space, and blood flow. These three things require the patient to be active in their therapy which gives them control.
Many of the patients with chronic conditions had stopped doing the things they enjoyed. Giving them activities which they can do without perceiving pain, or that can help decrease their pain, shows patients that they do not need to rely on external passive interventions to feel better. Getting patients to believe/understand that they have the control and power to make themselves feel better is one of the most important things a PT can do.
Mirror therapy, sensory discrimination, and PRI
Learning how to use different interventions to help decrease sensitivity and pain was huge for me. We used mirror therapy with different types of patients whether they had chronic pain or were post-surgical. The mirror activities usually started with the patient moving their unaffected limb while watching their affected limb move in the mirror. For example, if you right arm hurts you’d move your left arm while looking at the mirror because it would appear that your right arm is moving. We would progress patients to where they were moving their affected limb behind the mirror while still watching the reflection of their unaffected limb moving in front of the mirror. With the example above, you would still be watching the reflection of your left arm in the mirror making it look like your right arm is moving but would also be moving your right arm behind the mirror. This helped introduce patients to moving a sensitive area without experiencing pain, thus decreasing the threat of movement.
Another intervention I had not used before was sensory discrimination. We used this mostly in our post-surgical or more acute population to help decrease the local sensitivity after an injury and to try de-smudgify (that may or may not be an actual word) their homunculus [note from Zac: Totally is].
Sharp-dull discrimination was used first, then we progressed to two-point discrimination and usually ended with graphesthesia. The progress for patients from not being able to discriminate between sharp-dull to having graphesthesia showed me how powerful the role of the somatosensory homunculus is in the pain experience.
And of course, I learned more PRI from Zac. He challenged me to use more integrated non-manual techniques with patients while also limiting the number of cues I used. This was great because it is very easy for me to over coach these techniques. He also gave me a better understanding of some of the big concepts in PRI, such as neutrality.
Neutrality vs Hypofrontality
Neutral is a huge word in PRI that is often thought of as the end game when in reality it is just the beginning of a PRI treatment. The end goal is to get someone alternating and reciprocal. The idea of neutral always made sense to me as a good goal for performance as “neutral” joint positions is where the greatest force would be able to be produced. Talking to Zac about this he brought up what Bill Hartman Grandpa 🙂 has said: Neutral is a neurologically prefrontal state in which learning can occur, as the prefrontal cortex (PFC) is active during tasks that require attention. However, this is not a state you want an athlete performing in.
An active PFC is good when athletes or patients are in rehab because their cerebellum and basal ganglia are learning new movements that can then be used with less activity from higher cortical areas during performance. The movements used during these activities can become reactive after enough learning, practice, and repetition (those 3 things go hand in hand).
During performance or training we would not want an athlete using the higher cortical areas that elicit attention as this would make them slow and inefficient. Instead, we would want them fast and efficient (ie reactive and reflexive). A transient state of hypofrontality allows an athlete to reach a state of “flow”, which Mihaly Csikszentmihalyi describes in his book Flow, which is where the highest levels of performance occurs. This would allow the lower reactive (cerebellum and basal ganglia) and reflexive (brain stem) centers of the brain to essentially take over making them fast and efficient.
So from a theoretical neurologic stand point you do not want an athlete in a prefrontal state during performance. Good rehab and programming can help them become alternating and reciprocal through graded exposure and relearning of certain movement patterns in a neutral (prefrontal) neurologic state. Once this foundation is there, power and capacity can be added through training (which Zac talks more about here ). This may allow an athlete to stay alternating and reciprocal during transient states of hypofrontality when performing, not “neutral”.
Another concept that stood out to me from talking with Zac is the difference between extensor tone and extension. Extensor tone is necessary for power production during performance but it does not necessarily mean that the athlete is going into a position of extension. When someone is in extension they limit their degrees of freedom for movement and thus their movement variability. Using extensor tone from a neutral position, for lack of a better term, would allow them to display power while maintaining their potential movement variability (be alternating and reciprocal). This idea was something that made things click for me.
I learned a lot from Zac and want to thank him for all his help and time he spent teaching me. Needless to say, this was an amazing clinical internship for me and I cannot recommend enough that other students should try to get Zac as their CI or for patients to get treated by Zac. He is the real.
And now what everyone has been waiting for… Zac quotes
Help for cueing exercises
“Shakin’ like a polaroid picture”
“We don’t want Fat Joe and the lean back”
“Do you remember the three little pigs? I want you to be the big bad wolf and blow their house down”
“Do you have the big 3? Jordan (L abs), Pippen (L adductor), and Rodman (L glute med)?”
“We like a tight right butt and we cannot lie, the other therapists can’t deny”
“I’ll start calling him Buffalo Bill, cause he’s abducting like crazy”
“We don’t want you to have hamstrings like Goldmember”
Zac after getting his wisdom teeth out, he doesn’t remember saying these things
“I have lateral trusion!”
“Check out this IR” and then he self-tested his own HG IR
“I ain’t got time to bleed”
“Nobody makes me bleed my own blood”
“If you ain’t assesin’ you guessin’”
“There’s 45 miles of nerves in the human body if you put them all in a straight line, but don’t try it at home cause you’ll die.”
“…hmm..interesting” in Bill Hartman Grandpa’s voice
“…sure about that?” in grandpa’s voice
“Her teeth told me she had bunions”
“I don’t know why he told us the same diagnosis five times.”
“Breathing is really important. The research has shown if you don’t do it you will die”
“How about this word, variability. How about this word, salience. How about this word, anti-fragile. How about this word, POTS.”
I recently made the trek to Vermont for the first rendition of PRI’s Cervical Revolution course; a course in which the attendees doubled the population of the entire state.
It was nice to go to the class with a bunch of old friends. You always learn better that way, and I couldn’t have been more excited to get the band back together.
And even more so, I got to meet a lot of good folks for the first time. It was a real treat.
This course was meant to update the former craniocervical mandibular restoration course (which I reviewed here and here), with extra emphasis on the cervical spine and OA joint.
In this blog however, I will not touch much on the cervical spine positioning. I still have several questions regarding the mechanics. Some spots within the manual seemed to be conflicting; the blessing and curse of a first run-through. I will update this piece once I get these points figured out.
That said, the revolution helped fine tune the dental integration process for me. I have been working a bit with a dentist, and I have a bit more insight in terms of what devices they are using for whom.
Let’s go through my big a-ha moments.
The human body is symmetrically asymmetrical. When we have capacity to alternate and reciprocate, we are able to separate the body into parts to form a whole.
If you lack integration, then there are no parts. You have an it. This is how somatosensory smudging works. Lacking parts creates a pattern. A pattern could create a threat to the system, or a threat to the system could create a pattern.
We need to be able to differentiate our parts.
Neck Problems Do Not Exist
The craniocervical region is incredibly mobile for a reason. That reason is to create precision for our sensors: vision, audition, olfaction, respiration, and vestibular sensation. This precision occurs reflexively, whereas other appendages act proprioceptively.
These sensors drive the neck. Losing the ability to sense is what can increase the need for a neck to become stable. And when you can’t move a stable neck, teeth may be one thing you try to use.
In this course, the sensors we focus on are our canines and molars. Canines are transverse-plane antennae; necessary for lateral guidance. Molars, on the other hand, let us know what side we are on (frontal shifting).
Two TMCC Possibilities
Ron spent a much greater amount of time discussing two patterns that were briefly mentioned in previous courses: the left sidebend and right torsion.
These two patterns are possibilities that can occur at the cranium in a right TMCC pattern; and it all depends on what happens at the sphenoid.
The Left Sidebend
The left sidebend pattern is typically what we think of with the RTMCC. The atlas is rotated to the right, the occiput rotated to the left, the sphenoid oriented to the right, and the mandible oriented to the left. This positioning cants the mouth left and upward; creating a counterclockwise facial rotation.
It looks like this:
Test-wise, these individuals are limited in cervical sidebending to the right and axial rotation to the left.
Treatment will consist of developing left sided awareness, especially of occlusion. We want left abs to coactivate with a right SCM to establish neutrality. Here is the base repositioner to do that:
Here is where things get a little crazy. In these individuals the atlas, sphenoid, and mandible are right oriented; with variable positions occurring at the remaining cranial bones. This creates a right mouth cant and a subsequent clockwise facial rotation. This cant begets an over-referenced right sided occlusion which can become difficult to move out of.
It looks like this:
Test-wise these individuals will have bilateral limitations in lateral flexion, yet left axial rotation alone shall be limited.
These individuals will likely need some dental integration due to the over-right lateralized cranial positioning; many of these folks have had craniocervical trauma.
Therapy treatment will involve alternating activity, and here is our repositioner for that:
Splints on Splints
One of the big reasons I took this course again (aside from having a con ed problem) is because I wanted to really iron out who ought to get what splints. I definitely learned a much better appreciation for each splint type PRI recommends, and it was nice to see what new stuff they are using. Here are the big ones.
The PRI MOOO
This splint is the new one PRI is making, which is similar to your typical flat plane splint. The big difference is the anterior portion of the splint is built up to allow for better canine reference. Canines are what allow an individual to twist and turn, so the better we can feel these guys the better triplanar capabilities we will have
Who gets it: RTMCC folks; those who have a hard time finding teeth, more neurologically unstable folks.
The Gelb Splint
This guy is the one I was given. This splint helps bring the mandible slightly forward, creating better craniocervical mobility. There is also a lingual bar to reduce tone on folks with active tongues.
Who gets it: Individuals with narrow bites, active tongues, people who talk a lot throughout the day, one who can protrude the jaw forward, disc issues. Generally people who are fairly stable will get these, as they allow for much more movement freedom compared to the MOOO. Makes sense now why I was given this as I had no patho-compensatory patterns.
This device helps retrude the cranium to improve an airway and is usually worn only at night.
Who gets it: Right torsion patients, those with discal compression, individuals with sleep apnea, prophylactically.
These are the expensive beasts. It is an appliance that is worn around the maxillary and mandibular teeth to promote maxilla expansion and cranial flexion. You will likely need orthodontics after this one, as the teeth have a tendency to move.
Who gets it: Individuals with high palates (bilateral or unilateral), individuals who are very neurologically unstable, excessive disc popping.
So there it is. While it had the first-run bumps, this course’s information is priceless; necessary to truly integrate PRI to it’s fullest potential. Attend, find yourself a dentist, and help some people.
Infamous Ron Quotes
“There is a lot of feet in your mouth.”
“Foramen magnum is life.”
“Upper trap is a thermostat.”
“I want to twist the hell out of you so you can untwist and enjoy life.”
“You will never develop abdominal obliques without lateral pterygoids.”
“Dysautonomia is a bad ebola.”
“I’m no different than your protoplasm.”
“If you like feet you gotta like neck.”
“That’s called vagal sciatica.”
“Is it okay if I produce and Arnold Chiari syndrome on you?”
“The best physical therapists are ones who integrate with other disciplines.”
“The best sensory organ you have is your teeth.”
“Cervical revolution is a gift.”
“If you don’t like your spouse give them a NTI.”
“A hyoid that’s high is a cranium that’s forward.”
“You stretching out a neck is not going to get a cranium to go back.”
“The worst thing you can say to a patient is don’t do it.”
“There is no effectiveness in treating a symptom.”
Mike Cantrell was in my neighborhood to teach Myokinematic Restoration by the folks at PRI.
And I couldn’t resist.
This is the third time I have taken this course, a course I feel I know like the back of my hand, yet Mike gave me several clinical gems that I want to share with y’all.
This post is going to be a quick one. If you want a little more depth, take a look at my previous myokin posts (See James Anderson and Jen Poulin). Or better yet, take a PRI course for cryin’ out loud.
Hip Extension, We Need That Yo.
Sagittal plane is your first piece needed to create triplanar activity. Since this is a lumbopelvic course, we look at getting hip extension as high priority.
If I am unable to extend my hip, here’s what I could try to use to do it:
SI joint compression
Anterior hip laxity
Gastrocnemius and soleus.
We use two tests to see if we have hip extension: adduction drop (modified ober’s test) and extension drop (Thomas test).
The adduction drop will look at your capacity to get into the sagittal and frontal plane, and the extension drop test will look at your anterior hip ligamentous integrity.
A positive extension drop is a good thing if you are in the LAIC pattern. It means you didn’t overstretch your iliofemoral and pubofemoral ligaments. Well done! The reason why this test is not a hip flexor length test has to do with the femur’s position. In the pattern, the femur is positioned in a state of internal orientation secondary to an anteriorly tipped and forwardly rotated pelvis.
Due to this orientation, the femur must be externally rotated during performance of an extension drop test. This would put the psoas on slack. If you still have a positive test, then we know the anterior hip capsule is intact because that’s the only thing holding the hip up.
We spent a good portion of the day learning about gastrocs. In the LAIC pattern, the right gastroc runs the show as a hip extender AND hip external rotator.
The slight inversion action that the gastrocneumius performs helps pick up the transverse plane slack that the right glute max is malpositioned to do so. This is why the right calf is usually larger than the left.
This test’s pinnacle is the 5/5, to which gives us ground to become alternating and reciprocal warriors.
Just because you can hit 5/5 on both sides does not mean you can alternate well.
I was a prime example in class. Mike had me demonstrate my HAdLT in class, to which I easily hit 5’s on both sides.
Despite my quest towards neutrality, I have not been able to keep good thorax and neck positioning. Thanks wisdom teeth.
So Mike checked my right shoulder internal rotation, to which I had about 70 degrees. Way better than the previous 10 or so degrees I started at.
Then Mike had me perform the left HAdLT, which pushed me into my right hip.
Shoulder internal rotation worsened to 30 degrees.
He then pushed me into my left hip with the HAdLT.
Shoulder internal rotation now 90 degrees.
Even though I can crush the lift test, I do not alternate well because I lose position at other areas.
To truly be an alternating and reciprocal warrior, one must be able to perform alternating activities without losing position anywhere in the body.
Why Can’t I Swing my Right Arm?
In many folks with a LAIC/RBC pattern, you will notice that there is minimal right arm swing. You would think that the right arm would be activity secondary to right lateralization and hemisphere dominance. Not necessarily so though.
Arm swing is dependent on trunk rotation. If the trunk can rotate, then the arms can swing.
In the pattern, it becomes very difficult to rotate the trunk to the right, which mean there is no need for right upper extremity extension. So how about instead we just plaster the arm the side? Not a bad idea.
Crazy Good Cues
To close, Mike is a cueing machine. I picked up three new favorites that we’ve been playing around quite a bit in the clinic.
Press heels down on a chair to decrease TFL. Don’t use a ball because the TFL will attempt to adduct the femur via internal rotation. Then slowly add the ball.
Sigh upon exhalation if you have a patient who is rectus-dominant.
Plantarflex the first big toe to feel the left IC adductor in standing.
“Orthopedic symptoms are the result of bad neurology.”
“Good posture compromises respiratory dynamics.”
“Think before you stretch.”
“Stretching is the equivalent of kicking a horse while pulling on the reins.”
“99% of righties have a left thing.”
“Doesn’t matter what the diagnosis is.”
“Give me sagittal or give me death.”
“Most strength deficits are motor control deficits.”
“Total arc depends on what moment in gait you are in.”