I went to this course for a few reasons. First off, I of course support the home team. I can’t even front, Douglas Kechijian, Trevor Rappa, Greg Spatz, and I go way back, and are very much related through IFAST family and directly (Doug is my younger older brother, Trevor is my son, and Greg is my stepson #dysfunctionalfamily).
That said, there is were a couple big things I wanted to take away from this course, which I did in spades:
Mastering basic movement
In these two areas, the Resilient fellas delivered in spades. Knowing what good technique is in the basic movement patterns, how to coach, and how to regress, are all underappreciated topics that these guys teach quite well.
So should you take this course? An emphatic hell yes. I give a more indepth review as to why in the video below, so go ahead and check that out.
Once you got the verdict, check out my favorite takeaways in the course notes, and then for the love of God sign up for a course of theirs!
Click here to check out the Resilient Seminar Page
Did you miss Movement Debrief live yesterday? Though much more fun live, I have a video of what we discussed below.
This debrief was quite fun, as we had an impromptu viewer q&a. Thank you Alan Luzietti for the awesome questions! If you follow along live on Facebook or Youtube, I will do my best to answer any questions you ask.
Yesterday we discussed the following topics:
Why you should emphasize sagittal plane activities longer than you think
How to coach exercises to maximize client learning and compliance
Why detaching from your client encounters makes you a better clinician
Viewer Q&A – “centering from the chaos” & TFL Inhibition
Lastly, if you want the acute:chronic workload calculator I spoke about, click here.
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.”
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: