One of the many reasons I was drawn to make the trek to Lincoln was to experience my man James Anderson’s original affiliate course.
I always enjoy hearing James’ perspective on PRI, and he did not disappoint here.
The course felt like an Impingement and Instability with a bias towards the geriatric/chronic pain populations. Some might argue that James is the king at implementing PRI here.
I really admired James saying throughout the course that the Geriatric population houses his favorite athletes, and they really are. High performance at any task, be it sprinting 100 meters or walking to pick up the mail, require similar alternating and reciprocal components. We still go after the same pieces to achieve different goals along a continuum.
So let’s dive into this high performance course for some high performing individuals.
PRI 101…or at Least the Pieces You Didn’t Get from My Other Reads
The affiliate courses have a huge introduction that gives an overview of PRI principles, namely the Left AIC and Right BC patterns.
I’m not going to go through all the nitty gritty as this course did, but instead I’ll review concepts that James cleaned up for me. Think of this post as an in-depth FAQ.
The big keys you need to know about PRI if you haven’t already been reading my stuff.
We are asymmetrical in form and function.
Our respiratory and neurological lateralization drives us to being right-dominant individuals. We normally favor right-stance.
If we stay lateralized over time, it becomes much harder to break this pattern. We become neurologically rigid (credit the term to my boys Bill and Eric) and lose triplanar capacity to move.
The goal is to manage these asymmetries so we can establish alternating (what happens on one side the exact opposite occurs on the other) and reciprocal (a joint goes through the full range of motion in one plane) activity.
We achieve alternating reciprocal function through respiration. Breathing regulates and balances the nervous system, which PRI values as most important. Combined with knowledge of triplanar biomechanics, and we can see what PRI focuses on:
What the Hell is a ZOA?
The ZOA, or zone of apposition, is the portion of the diaphragm that is directly adjacent to the inner aspect of the lower rib cage.
As we fully exhale via concentric abdominal activity, the ribs go down and in. We establish a ZOA. As we inhale, the abdominals eccentrically maintain a ZOA. The ZOA allows the diaphragm to stay domed and function maximally for respiration.
Comparing right and left diaphragms, the right diaphragm is better predisposed for many reasons to have a better ZOA than the left. This dominance via the right diaphragm’s large crura pulls the lumbar spine to the right.
The left diaphragm is shortened and better able to act as a postural muscle; pulling the spine into extension; becoming an agonist to the paraspinals.
Ergo, we want to do what is possible to establish a ZOA on the left. This piece is foundational for transitioning into left stance.
Ok, so Right Diaphragm is King. What else Lateralizes Us?
The triangularis sterni/transverse thoracis is built to combat left chest wall hyperinflation. Its fibers on the left side extend up to the second rib, which is one rib higher than on the right. Since this muscle is a powerful exhaler, this asymmetry helps promote greater exhalation from the left chest wall.
The other obvious asymmetry includes the lungs. The right lung has three lobes, and the left two. Aside from the right mediastinum containing less stuff, these lobes helps maximize alveolar air exchange when the pressure gradient is adequate for right chest wall airflow. The left chest wall easily pulls in air, so only two lobes are necessary for adequate oxygenation.
Neutral Neutral Neutral. You say that all the time. What’s that?
Neutrality is a state of rest; a transitional zone.
Moving in and out of neutrality constitutes going from one end-range of motion into a transitional zone between the other end-range of motion. This transitional zone is where neutrality lies.
When we are in a neutral state, our body stops moving and attempts to rest. We need this state so static activities (e.g. sitting, sleeping) are performed without excessive tone. Finding this resting point better allows us to move out of this state during dynamic activity.
Neutrality reduces our normal right lateralized bias and maximizes capacity to move in three planes bilaterally.
“Neutrality is not a point on a map. It’s a parasympathetic state of being.” ~ James Anderson
Alternating and Reciprocal Stuff
As stated above, alternating activity is when what occurs on one side the exact opposite occurs on the other; reciprocal activity is a joint going through full range of motion.
However, an interesting concept was presented at this course that I haven’t thought about. Just because one a joint is in one position on one side doesn’t mean the opposite must occur on the other side.
Take this example. Let’s say that I am in right stance. My trunk would normal rotate to the left. What happens if I need to see something occurring to right while I am on my right leg?
Obviously these situations do occur. Therefore, alternating reciprocal activity constitutes that if I am on my right leg, my trunk could go right or left. I have options to have my body move in an ipsilateral or contralateral fashion.
Why Does Humeroglenoid (HG) Horizontal Abduction Test Thoracic Rotation, and Why does it Become Limited?
In the right brachial chain (RBC) pattern, the thorax begins to rotate to the left via left rib external rotation and right rib internal rotation. Due to this ribcage activity, the sternum is rotated to the right, and the left chest wall is hyperinflated.
The left pectoralis major is what would limit horizontal abduction in this case. The attachments for the pec include the sternum and the lateral lip of the bicipital groove. If the sternum rotates right, the pec elongates. The pec major is also an accessory inspiratory muscle, so it becomes neurologically active to attempt to draw air into the hyperinflated left chest wall.
Since the left abdominals are not in a position to create a ZOA, the pec is unopposed. Pec major tone limits horizontal abduction; thus signifying limited right thoracic rotation.
You Mean Someone Actually Talks about the Bilateral BC???
There is a case in which both sides of the thorax become extended, hyperinflated, and ribs become externally rotated. This state is known as the bilateral brachial chain (BBC).
This positions leads to both hemidiaphragms functioning as postural stabilizers more so than respiratory muscles.
Trunk rotation would not occur on either side, thus horizontal abduction would be positive on both sides.
A New way to think of tests
There were a couple seated tests that were introduced in this course, but one big key was talked about regarding all the PRI functional tests:
Do they feel the same on both sides?
In other words, if a muscle contraction is to be felt during a portion of the test, is the contraction an equal intensity on both sides. If both sides are not equal, that may affect the way you decide to grade your tests.
How be Dem Feets of Yours?
In the left AIC pattern, the left foot is in an everted and pronated position. Whereas the right foot is in a more inverted and supinated position.
If the right medial longitudinal arch and calcaneus do not have enough support, be it from tissue or footwear, the right arch and medial foot may collapse to reach the floor. This foot is not pronated however, but is pronating.
If the feet have gotten to the point in which this pattern cannot be overcome, supportive footwear may be indicated. The keys to a good shoe include:
Stable heel counter; both posteriorly and laterally.
This footwear allows for calcaneal frontal plane control and supports the medial longitudinal arch. The inherent forefoot flexibility supports gait propulsive forces.
Having good shoewear can better allow the patient/client to find and feel areas necessary for alternating and reciprocal activity.
Your Habits, They Kinda Sorta Matter
Look at your stove. Tell me which burner is your favorite.
Did you choose the bottom right burner? Why is that one usually the largest? It fits a pattern of right-handed dominance. A pattern of right lateralization. It’s normal.
James pointed out many different habitual things that could influence one’s position. Think about where you like to be in some of these examples.
What side of the bed to do you sleep on? If you like the right, you’ll reinforce the Left AIC/Right BC. If you like the left, you are either neutral or patho.
What side of the couch do you nap on? The right side is usually preferred; especially if lying on the right side. If you like the left side of the couch and face out, you likely have a patho thorax.
Which island in your kitchen do you like? Assuming equal cupboard space, you probably prefer the island left of the stove compared to the right. Left island allows for right reach
There were many other examples that demonstrated the way our lives influence our patterned behavior. Making people become aware of these tendencies, and showing strategies to affect these preferences could be a way to help one integrate alternating reciprocal activity throughout the day. I can envision teaching someone to cook on their left burner as their HEP.
“Patterns develop into preferences.” ~ James Anderson
Stretching doesn’t work because it doesn’t shut tone off. Tone is increased because stretch is a force that is thrown at the system. The system responds to this force by increasing tone.
Torsion = compression. Think the lower back.
In the Hruska Adduction lift test, the bottom leg is looking at stance phase, the top leg looks at swing phase of gait.
In the Hruska Abduction lift test, the top leg is in swing phase, the bottom leg is in stance phase.
When treating someone, go after the most limited snowball (sacrum, sternum, sphenoid).
Home Integration Exercises
James gave many examples of what exercises might be beneficial for different situations (bed mobility, transfers, gait, etc). There were several neat exercise variations he introduced. I’ll show you some of my favorites.
This first activity helps establish a ZOA while rotating the trunk to the right. An easy way to slowly expose a right lateralized system to the left.
A neat trick when sitting is to press the back of your leg into an object to get left hamstring.
Also really loved how flexing the hip isometrically into a table intensified everything in this left stance exercise.
James also gave us several little tips and tricks to help improve exercise performance:
Use several pillows to flex the patient and achieve a better ZOA.
Use toilet paper rolls to create isometric adduction.
Use paper towel rolls if one must move his or her hips during an activity; these roll better than toilet paper for example.
I can’t say one bad thing about this course. In fact I’d say I got more out of this course than I thought I would. This was the best overview of PRI that I have witnessed.
For newbies to PRI, you will get blasted with a lot of content, and it won’t be easy to digest the first time around. The manual is so well done though, that this course provides a great way to learn the most about PRI in the broad sense. You could most certainly start your PRI journey here.
For the vets, concepts will become better understood and you will get some great exercise variations.
So should you check out PRI Integration for the home?
Great James Quotes
“Recliners are the thing.”
“Geriatric clients are my favorite athletes.”
“Toilet paper rolls are neural integrators.”
“Treat patients how they feel inside.”
“That’s like influencing your mother.”
“The diaphragm is the core of your core.”
“The brain is amazing because it can adapt to anything.”
“All human beings are right-sided dominant in everything.
“If you are one step ahead of the crowd, you are a genius; if you are two steps ahead of the crowd you are a crackpot.”
“If you’re not domed, your toned.”
“People cannot rest themselves.”
“Do you know any stretch that says take 3 breaths, clap your hands, and smoke a cigarette that gives you 40 degrees of shoulder motion?”
[on PT school] “You are going to charge me this much and give me three sentences on breathing??!!? You should give me three months! You should be ashamed.”
“Don’t blog that.”
“If I have 45 degrees overall in a muu muu I’m good.”
“Nobody in that Medicare room knows anything about gait.”
“Rod Stewart was dancing? He’s probably on amphetamines but good for him!”
“We’ve got a before collapse party and an after collapse party and the minimalist shoe wear goes to the after collapse party.”
“Whoa! PRI does nothing.”
“The left pelvis is different from the right. Drink!”
“Just blow the dang balloon up.”
“Recliners shut off people.”
“In a grandma course, really?”
“Don’t shift if shifting is irrelevant. Reach.”
“The diaphragm is your prime mover of the spine.”
“Don’t train not sure.”
“There is no problem with the pattern. The problem is when you can’t flip the coin.”
“The Timed Up and Go Test aka the hurry up and fall test.”