You shed that mindset with the game on the line. You must do all in your power to get that player back on the court tonight, expediting the return process to the nth degree.
I had a problem.
Figuring out the most efficient way to treat an ankle sprain was needed to help our team succeed. I searched the literature, therapeutic outskirts, and tinkered in order to devise an effective protocol.
The result? We had 12 ankle sprains this past season. After performing the protocol, eight were able to return and finish out the game. Out of the remaining four, three returned to full play in two days. The last guy? He was released two days after his last game.
It’s a tough business.
The best part was we had no re-sprains. An impressive feat considering the 80% recurrence rate¹. Caveats aside, treating acute injuries with an aggressive mindset can be immensely effective.
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!
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.”
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’ve only read book 1 thus far, but this book can generate material to expand upon much like Supertraining does for fitness writers.
I’m sure many of you folks have seen this picture before.
Gifford called this schematic the “Mature Organism Model” (MOM) to illustrate how pain works.
Inputs from the tissues and the environment travel up the spinal cord to the brain. The brain processes these inputs and samples information from itself to generate a corresponding output. These outputs are perceived as new inputs which reset the cycle.
MOM was of course used to illustrate the three pain types (read here and here), but it is so much more than that.
The MOM is a schematic for how the nervous system works.
Any input that is processed by the brain may or may not lead to outputs of altered physiology and/or behavior.
Viewing (your) MOM (ha) made me think a lot about working with individuals who are dealing with a threat response. How exactly are we helping these folks?
I’ve come to believe that we do not treat outputs. At best we can only provide inputs that we hope are exchanged for new, desirable outputs. In patient care, we are hoping to alter perceived threat. We attenuate threat by giving an individual favorable inputs, which we hope leads to favorable behavior and physiological changes.
Let’s look at what these favorable inputs are by looking at MOM a bit more in-depth.
The Three Inputs
The nervous system can receive information from body tissues, the environment, and itself. Therefore, these are the areas in which we shall provide favorable inputs.
The three input types that can favorably affect the nervous system are:
These inputs can be provided by the individual themselves, someone else, or a foreign object. All three will be needed to some degree, but some will be needed more than others depending on the goal. Let’s dive further.
This input occurs by providing information through tissue receptors. Input types will include most conventional and alternative medicines and performance training.
The primary things we are looking to change with these inputs are:
System variability – The range at which a system can act
System capacity – The volume a system can perform with.
System power – The intensity a system can perform with.
Life is a balance between these three system components, and the degree to which a system must have these components is tailored to an individual’s needs. (ps, my Dad is going to talk about this much better than I here).
Since I am assuming most of my readership is in the movement business, we can look at the movement system.
Movement variability is the ability to move through full ranges of motion actively and passively in three planes. Variability in the movement system follows a bell curve, with movement rigidity for our hypomobile folks and pathological movement variability for our hypermobile folks.
Most conventional therapies that aim to improve mobility and motor control are typically dealing with movement variability. To me, the best system for managing movement variability is PRI, as it is the only one that looks at one’s ability to move well in three planes.
Movement capacity would be how long one can perform before fatigue. Think of any type of training that gets you to do something longer (e.g. aerobic conditioning) as capacity training. In the PT realm, I see graded exposure the way Butler, Louw, and other pain science advocates espouse as building capacity. This training methodology is no different from your favorite conditioning methods.
Movement power would be increasing the force produced in a task. Think weight training and the like.
The target input here is the individual’s environment, and I would argue that this is the most important, and sadly under-discussed, input that a clinician utilizes.
This input’s goal is to create an environment that allows for desired outputs to occur.
If you are a clinician treating someone in pain, you are going to be friendly, funny, empathetic, and an excellent listener (and do stuff I wrote here). Your clinic may have calming colors and scents, and you may want to boot out family members that stress your client out.
If you are a coach getting someone strong, you’ll probably want a bunch of like-minded clients working together getting amped up and playing “my mother never loved me” music.
If you are an individual who lives in a stressful environment, you might change that input by leaving that stressful environment, changing jobs, moving to Arizona, etc.
Here we are providing an input that affects the brain’s self-sampling; the mindset. Knowledge is power. The most common discipline that utilizes this input is psychology.
In the movement realm, this input is where therapeutic neuroscience education fits in. This methodology expunges old, deleterious thoughts while simultaneously providing the individual with new, nonthreatening thoughts. This exchange can reduce threat from other inputs.
We provide favorable inputs this way anytime we learn something. Every time you read something educational you are creating new inputs for the brain to sample.
Categorizing an input depends on primary intent, but there are several instances in which inputs overlap. We should categorize these inputs via primary, secondary, tertiary intent. For example:
Putting a hand on someone while they are crying (Primarily therapeutic interaction as you provide an environment for healing; secondarily therapeutic intervention because the touch may provide a calming effect on the nervous system through cutaneous receptors).
Telling a funny story to educate someone (Primarily therapeutic education because that individual is being provided new beliefs; secondarily therapeutic interaction by making the client laugh).
This favorable input model provides some insight as to how our clinical/coaching processes can affect the outcomes we seek. While we may have our strengths, creating desired adaptations requires excellence with all three of these inputs.
The best exercise program in the world will not be effective if a client does not does not like you just as your niceness will not outdo your outdated treatments.
Which of these three inputs do you excel at? Which need work? Comment below.
I officially became a Jedi this past December after retaking Advanced Integration and going through the Postural Restoration Certified (PRC) testing.
Both were a wonderful experience in terms of learning new concepts and fine-tuning old ones.
Since I have retaken this course, I will not go into huge detail in terms of the material covered (if you want detail, read last year’s AI notes here, here, here, and here).
Instead, I will reflect on a few concepts that really hit home for me (No, i’m not saying what we did at the PRC)!
Extension is Evolution
Extension is what allowed our brains to develop because it brought us to two legs.
The big extenders: psoas, paravertebrals, lat, QL, capitis
Extension given us more but comes with a cost. As we continue to extend, we increase system demands. Extension will likely be a necessary adaptation to live in the world we are creating.
I’m scared to see what the future looks like.
Refers to triplanar position of the body. Neutrality is the state of rest and transition zone from one side to the other. We want this most of the day, but can’t expect this to occur all day. We want to establish a rhythm in and out of neutrality in alternating and reciprocal function.
The alternating and reciprocal rhythm has alternate appendages on either side of the body. When the left leg is in front, the right leg should be back.
In right stance, the appendages take the following positions:
Legs – right back, left forward
Arms – right forward, left back
SCMs – Right back, left forward
Lateral pterygoids – right forward, left back
Extra-ocular muscles – right back, left forward
In left stance, the above positions are reversed.
Oftentimes one or many of these appendicular positions is flipped. This flipping is when you have defensive patterning (LAIC/RBC/RTMCC/PEC).
Position is More than the Body
Position extends beyond body states. Position reflects who you are.
There was a table regarding human asymmetrical concepts present in this year’s manual that listed characteristics of neutral versus PEC individuals.
It blew me away because it very well matched my personal transition; especially comparing how I am now to when I was a young lad. Check this out.
Live, create, play
Work, formal, rigid
I’ll probably be in jail painting pretty pictures once my wisdom teeth are pulled.
Septums and Chambers
Septums are partitions in our bodies that separate chambers. For example, the diaphragm is a septum between the thoracic and abdominal chambers. These septums stiffen with flexion and loosen with extension.
We want septums to be tight, as septal tightness allows for chambers to expand, shift, and rotate. When a chamber can’t expand, it shall become loose.
If you want a tight septum you must be able to flex. Flexion is what gives one access to shift and rotate.
The normal respiratory cycle alternates between chamber and exoskeletal dominance. Upon inhalation, the exoskeletal system becomes unstable, but chamber pressure increases. When exhalation occurs, exoskeletal stability increases and chamber pressure decreases.
Thinking about this alternation clinically, one who lives in a constant state of inhalation (i.e. extension) will stay upright via chamber pressure. Stability is passive. On the flipside, one who spends more time exhaling (i.e. flexion) must keep upright stability via active elements
The rectum is shaped somewhat like a cone to which a pressure gradient for defecation occurs by gravity and peritoneal cavity shape.
Our natural human asymmetry is necessary to mobilize abdominal contents. Our iliums act as pumps for the rectum, shifting contents back and forth with each step we take.
If we only have access to one phase of gait though…things get shitty.
Create with Your Arms
Hands should be free to reach and create, but when we are in a protective pattern, inability to reference the ground through our legs leads us to find reference elsewhere.
In some individuals, the arms can act as a reference center to hold us upright. This occurs most notably when we lack transverse plane activity. If you see these behaviors, think need for transverse plane:
When one writes, they push the pen into the table as opposed to gliding it across paper.
Hands in pockets (guilty as charged).
When you have people who cannot create with their arms, being able to feel the ground is one of the best things you can do. Ground push-off is what reduces the reference needs of the arms.
It’s Not Illegal for your Right Ab Wall To Engage
One of the biggest mistakes I made was losing a right zone of apposition (ZOA).
A slight right ZOA is necessary when creating right apical expansion. The LAIC/RBC/RTMCC pattern dictates the ribs on the right are closed down. Airflow ought to be used to open up these ribs.
However, if I lose the ZOA on the right by letting my ribs flare and over-externally rotate, the right ribs will stay compressed. All that will be stretched is the right ab wall.
Conclusion: exhale and keep the ribs down and in on both sides. Then upon inhalation, a stretching sensation should be felt in the right intercostals. You won’t take in much air.
It is Illiegal to Overflex
We don’t want turtle humps, as this would be the same as creating excessive kyphosis in standing.
Instead, what we want is appropriate kyphosis via posterior mediastinum expansion. Get a ZOA, keep the ZOA, then inhale.
Mirrors are Cool
We learned some neat tricks you can do with a mirror. The mirror takes away visual reference by disassociating what is being seen from what is being felt.
This strategy is especially useful for people who can’t find and feel muscles on one side but can on another. Check out the video below to see an example.
Public service announcement: When getting your eye exam, ask your optometrist to make sure that you are not overcorrected and that your eyes work together or are balanced. These changes alone will make visual information coming into your brain less threatening for the system.
I came with a new appreciation of the subtalar joint. It’s a triplanar ball and socket-like torque absorber that creates pronation and supination.
This rotational force is not always occurring by the leg muscles however. In the closed chain, the opposite hip swinging forward creates supination in the foot. The effect is like a ratchet (twister is the pelvis, stationary end is the lower extremity).
This rotational component is one possible reason why many orthotic therapies can fail. A foot orthotic must be able to return the entire lower extremity to the center of the frontal plane (i.e. neutral).
Contrary to the haterz, orthotics will not weaken the foot. What they are made to do is change proprioceptive inputs that can have an effect on motor learning. Orthotics can allow one to find and feel muscles they may have not felt before.
It’s a different sensory experience, just like anything you wear is.
Even though PRI likes its orthotics, you may not always need shoes. Sometimes you can gain greater proprioceptive feedback to sense the floor barefoot. It’s going to be person dependent.
The verdict? Wear many different shoes and go shoeless occasionally. Give your dogs variable sensory inputs.
Infamous Ron Quotes
“If you’ve got rhythm you’ve got a diaphragm.”
“You should be moving so sinuses can drain snot.”
“If your gut is moving the bowels in your lungs are moving.”
“You have a center of your body…And I’m going to do this a lot…But it’s not the center of your body.”
“You have to handle the big G in some way.”
“What is this guy nuts? I am nuts.”
“Do something to become alive.”
“Wear different shoes everyday and you’ll probably poop.”
“If you cannot exhale you are probably dead.”
“Is your septum tight? Mine is.”
“If you don’t own yourself you can’t be kind.”
“I gave you these tests just so you would wake up.”
“It’s cool to be twisted.”
“If you suck at twister you can’t uncoil.”
“I like to break the law once in a while.”
“If you are going to do PRI, underbreathe.”
“Pain distorts where you are at.”
“Gosh, all my patients are snakes.”
“Quadratusitis. It preceded ebola.”
“The more references you have the less obese you will be.”
“Curvatures run the show.”
“Really? We’re going to fight to move a joint through a range?”
“Leave the body alone unless you really have to do something.”
“Can you imagine me in black spandex? Or a penguin?”
“I have her in good shoes. She knows I have an attitude.”
“That old bald guy this morning…”
“Oh she’s shaking like a leaf.”
“I’m not afraid to say I don’t know.”
“These type A patients, and I don’t mean Hong Kong Taipei.”
“Neutrality is nothing. You need to be able to work with it.”
“It’s not illegal for your right ab wall to engage.”
“No! I’m sorry, just trying to find the floor on the left side.”
Great James Quotes
“You want to know why? Cuz Ron happens.”
“Extension is not bad if you can manage air and chains.”
“You can train everything but you don’t want to overtrain discord.”
“If you can’t trunk rotate you can’t ZOA incorporate.”
It’s that time of the year that we get to look back and reflect and what posts killed it (and which bombed).
It seems as though my fine fans be on a pain science kick this year, and rightfully so. It’s some of the best stuff on the PT market right now. It’s definitely a topic I hope to write about more in the coming year, and one I will be speaking on at this year’s PRC conference.
But without further ado, here are the top 10 posts of 2014.
Going through the treatment process as a patient has really upped my game in terms of knowing when to integrate with my patients. It has also been a life-changing experience for my health and well-being. Learn how they did it for me.
So much fine tuning occured the second time around. I love how Jen acknowledged the primitive reflex origin of the patterns, as well as fine tuning both lift tests. She’s an excellent instructor (and fun to party with)!
One of the most powerful and humbling courses I have ever been to. Ron goes all out on this course, as it is his baby. What dental integration can do to a system under threat is a concept that I hope is further explored in medicine. We can’t do it alone folks.
This post marked a shift in my thought process and a realization of the possibilities that an integrated health system can accomplish. I have high hopes for our profession, and feel excited that an original post had so many views.
Couple the best manual therapy explanation I have come across and a gentle technique and you get a rock solid course. The only downside is that now Diane has tarnished any other manual therapy course for me, as I can’t rationalize any other explanatory model given.
I really enjoyed this course because it was such a high-level affiliate and great prep for my PRC. We went into great deal regarding position, throwing mechanics, and treatment.
One of the most amazing pieces of the course was Allen’s ability to breakdown complex baseball movements into their basic biomechanical bits, And from that point show what compensatory things could occur if limitations are present. His eye for these things is unreal.
That piece of the course is a post or two on its own, so I won’t touch it here. In fact, I probably won’t touch it at all. Go to this great class and be wowed by Allen. You will be motivated to become a better clinician. I know I was.
Here are some of the big takeaways.
PRI 101 v 3.0
I’ve heard this overview three times this year now, and it is amazing that I still pick up things from it. James really outdid himself here.
The big piece this time around was space. We want space maximized.
In the vision course we discussed maximizing left peripheral visual space because the pattern reduces this quality. The pattern in general reduces our ability to move through triplanar space.
There are a few other reasons that we would be unable to shift into our left side. Overactive muscles chains may prevent this action, but we also have something very large occupying the left side.
We call this thing air.
If we are hyperinflated in particular areas (think left chest wall), how can we expect to go to the left side? Left space is already filled with air. Airflow must be transferred to the right side in order for us to maximally close down our left. Maximal left sided closure via a zone of apposition is necessary to create true left stance.
Patterns, Adductors, and Pecs (Oh My)
The right adductor magnus and left pec major, though not part of the LAIC/RBC pattern, are still very active muscles. Why is this so? These muscles prevent falling over when in right stance with left trunk rotation.
That PRI Doesn’t Work, I Got Someone Neutral and they Felt Worse
False! Here’s why.
An individual’s norm when under threat is the LAIC/RBC/RTMCC pattern. It’s autopilot; it’s what’s comfortable.
Let’s say you take that away from someone. They have greater movement freedom, but are not sure what to do with it or how to control it. This change could be perceived as a threat by the brain, and symptoms may increase as a means to prevent movement exploration into this new space.
I tell my patients when this happens it is like they just got their driver’s license and I gave them a Ferrari.
A Ferrari is a little more challenging to drive than most cars (so I hear, that blog paper hasn’t hit that level yet), so it’s going to be a bit harder to handle. Once the patient learns how to drive the Ferrari the possibilities are endless.
They must learn a new pattern (RAIC/LBC/LTMCC) in a nonthreatening manner so they obtain locus of control in this new position. Once integrity is achieved here, alternating reciprocal activity is ingrained to maximize movement variability.
Pattern Pitching Problems
Depending on what arm you throw with, you are going to have a bit more trouble with certain aspects of pitching movements. I won’t go into the bazillion reasons why this happens like Allen did (go to the course yo), but here is what each throwing phase needs.
If I’m a right-handed pitcher, the LAIC/RBC is going to limit me. Let’s break it down to each throwing phase:
Wind-up – Need to turn on right posterior glute med to delay LAIC activity.
Stride – Need to inhibit right adductor and QL to maximize stride length.
Cocking – Need to shift into Left AF IR while maintaining right trunk rotation.
Acceleration – Need to keep Left AF IR in trunk flexion.
Follow through – Need to balance into left AF IR.
If I’m a left-handed pitcher, the RBC, posterior mediastinum, and timing will be my largest limiting factors. Here is what I need at each component of throwing.
Wind-up – Need to load left AF IR and engage abs to stay back. Inability to do this is what creates that beautiful natural spin us lefties have when we throw.
Stride – Need to inhibit LAIC/RBC so one does not rotate too early into Right AF IR and right trunk rotation
Cocking – Need to control Right AF IR and left trunk rotation while reducing back extension and keeping adequate left posterior mediastinum activity.
Acceleration – Need to keep trunk closed down into flexion
Follow through – Need to balance into right AF IR.
Repetitive Rotation Superior T8 (Gasp)
This part was probably the most controversial and misunderstood piece of the course. The concept itself is not difficult to understand, but the material may seem challenging to fit into the PRI philosophy.
I’ve had several discussions with James Anderson on this topic to make the masses get the most up-to-date explanation for this pattern. Here is what we came up with [My post-conversation thoughts will be in brackets].
In the first two baseball courses, “repetitive rotation superior T4 syndrome” was used to describe a rare compensatory pattern seen in particular populations. James and Allen are now calling this pattern “repetitive rotation superior T8 syndrome.” The name changed because there are more ribs reversing the underlying LAIC/RBC pattern then the top 2-4 ribs. This change will be in all future baseball course manuals.
And now for the condition itself. There are certain instances, albeit rare, in which certain individuals may appear to have a reversed posturalpattern (RAIC/LBC). Repetitive right trunk rotation occurs via various trauma and/or functional demands, such as the deceleration thru follow-through pitching phase for a lefty or the back swing for a right handed golfer, creating a thorax that is driven to the right.
You can also see this in PRI junkies who bias the left side only and never alternate [Like a right-sided hemineglect neurologically. If right-stance activities are not appreciated, variability may lowered possibly due to disuse. One possibility for this is also losing appropriate right zone of apposition while in left AF IR, to which I will discuss in a future post].
This T8 syndrome differs from classic superior T4 because more drivers push the thorax to the right and externally rotate the right ribs. In the T4 case, the scalenes elevate the upper 2-4 ribs to meet excessive respiratory demands. In T8’s case, the left BC kicks into high gear and drives more of a PEC/bilateral AIC pattern. It may mimic a RAIC/LBC, but not be the case.
With the thorax rotating hard to the right, the pelvis and lumbar spine must orient left and into a pseudo-left AF IR translatory-type movement. Consequently, these folks stand and function quite well on their left leg compared to the right.
Seeing a “flipped” pattern is nothing to freak out about; there are still underlying LAIC/RBC patterning at play. This repetitive rotation superior T8 syndrome is an atypical compensatory strategy that requires atypical treatment.
Interventions basically flip normal PRI activities; shifting into right stance with left trunk rotation. We technically cannot call this “PRI” because the underlying human asymmetry is not addressed.
Treating in this fashion does however put the system into a “normal” asymmetrical pattern to which conventional PRI methods can be used. [That said, the name of the game has always been alternating and reciprocal activity. Everyone should be able to do traditional PRI activities on both sides without falling apart. The reason why this is not called PRI is because of the order treatment occurs in].
[The big message at the end of the day: Trust your measurements and treat accordingly].
Elbow and Wrist Drive Thorax
This portion was one of my favorite pieces of the course; namely because it’s not talked about anywhere else in PRI land.
There are 4 possible patterns on the left and right side that can occur at the humeral-radial joint; depending on the position of each.
I won’t go into details on each, but basically if you see increased mobility in one direction (supination or pronation), you likely want to inhibit that direction and facilitate the converse.
Wrist flexion, pronation, and internal rotation facilitate serratus anterior and contralateral thoracic rotation.
Wrist extension, supination, and external rotation facilitate lower trapezius and ipsilateral trunk rotation.
Reference centers in the wrist and hand can also be used to facilitate position. When attempting to facilitate left stance with right trunk rotation, use a right pisiform and left palmar arch.
So there you have it. Some of my favorite pieces from this excellent affiliate courses. It’s filled with a ton of information, and is easily the most challenging conceptually of the three affiliate courses I have taken. You won’t regret this one.
Great James Quotes
“If you see a forward head, hand them a card that says exhale please.”
“Inhaling in a state of exhalation is neurologically cool.”
“It’s not magic. It’s better than magic. It’s neurologic.”
“We’re gonna talk about trauma called throwing a baseball 95mph with your left hand.”
“That muscle firing is a total waste of sarcomere slide.”
“Your brain is a better parent of your body than I was my son.”
“Ron is looking at the brain, not the plumb line.”
“A plumb bob and grid is offensive to Ron Hruska.”
“What have you thought about the fact of never blowing up a balloon as a grown man?”
“He sucked a lot of balloons empty.”
“Hand on the heart for serratus anterior. Go ahead.”
Gruv-y Allen Sayings
“You are only as good as your patient will allow you to be.”
“I can’t stand research to a point.”
“The right QL and adductor are best friends…Just like James and I.”
“Don’t judge someone just by video.”
“You can’t make a program based on a screen.”
“If you’re not doing test-retest give them they’re copay back. You are failing them.”
“One pound dumbbells are not changing my patient’s lives.”