If you missed me live, you can check out Episode 4 of Movement Debrief below. We hit a small technical difficulty early on, but it all ended up working out.
We discuss the following concepts:
Why I Emphasize Hamstrings before quadriceps after ACL reconstruction
Why Hip Rotation isn’t always a reliable measure
Interpreting the Ober’s Test
Meeting the Patient’s Needs vs the Clinician’s Needs
I apologize that the quality is not so great. I’ve moved to a rural part of Arizona, which as of right now does not allow for the best of streaming. If you friend me on facebook, however, you can watch the live stream, which has surprisingly much better quality.
Click here for the post I mentioned discussing combining blood flow restriction training with E-stim.
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.
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.
Prompted by some mentee questions and blog comments, I wondered where manual therapy fits in the rehab process.
To satisfy my curiosity, I calculated how much time I spend performing manual interventions. Looking at last month’s patient numbers to acquire data, I found these numbers based on billing one patient every 45 minutes (subtracting out evals and reassessments):
Nonmanual (including exercise and education) = 80%
Manual = 20%
Modalities = 0%!!!!!!!!!!!!
Delving a bit further, here’s my time spent using PRI manual techniques versus my other manual therapy skill-set:
PRI manual = 14%
Other manual = 6%
As you can see, I use manual therapy a ridiculously low amount; skills that I used to employ liberally with decent success.
There’s a reason for the shift
I want my patients to independently improve at all cost and as quickly as possible. The learning process is the critical piece needed to create necessary neuroplastic change; and consequently a successful rehab program.
Note: I made some errors on the first rendition of this blog that were corrected after speaking with Eric Oetter. Courtesy to him, Lori Thomsen, and Ron Hruska for cleaning up some concepts.
Four Months Later
When the Lori Thomsen says to come to Cervical Revolution, you kinda have to listen.
I was slightly hesitant to attend since I had taken this course back in January. I mean, it was only the 3rd course rendition. How much could have changed?
Holy schnikes! It is simply amazing what four months of polishing can do. It was as though I attended a completely different course. Did I get it all figured out? No. But the clarity gained this weekend left me feeling a lot better about this very complex material.
This is a course that will only continue to get better with time; if you have a chance to attend please do.
Let’s now have a moment of clarity.
The craniocervical region is the most mobile section of the vertebral column.
This mobility allows regional sensorimotor receptors to provide the brain accurate information on occipital position and movement.
The neck moves with particular biomechanics. Fryette’s laws suggest that the cervical spine produces ipsilateral spinal coupling in rotation and sidebending. The OA joint, on the other hand, couples contralaterally.
C2 is the regulator of cervical spine motion; much like the first rib regulates rib cage movement.
C2 is also important for the mandible, as it balances the cervical spine during mandibular opening. The reason this occurs is because the mandible and C2 are at the same fulcrum level.
Often triplanar motion will decrease amidst progressive respiratory demand or threat. These changes help promote neck stability while simultaneously increasing demand on the mandibular elevators, extraocular muscles, and vestibular system
If these changes occurs long enough, sensory issues may become prominent.
Stability can occur through increased sagittal plane activity in the upper cervical spine and cranium either one of two ways:
O on A via posterior cranial rotation
A on O via forward head posture
Both strategies attempt to flex the cranium, but both are undesirable if occurring underneath a lost cervical lordosis.
OA hyperflexion is often seen in those who sit in front of monitors for long periods of time. The visual system helps promote stability.
OA Hyperextension is an attempt to create an airway. Cranial protrusion may be utilized as a way to open up the airway under stable conditions. This position passively raises the hyoid bone, which often depresses when one uses a mouth-breathing strategy. These individuals rely heavily on the dentition for craniocervical awareness.
Of course, these are not the only ways undesirable neck stability can occur.
You might have a stable neck if:
You have a narrow palate.
You have a cross bite.
You have a narrow airway.
Patterned Mechanics 3037
The TMCC is the foundational polyarticular muscle chain at the neck, with the right side generally more active than the left.
The normal RTMCC pattern presents with the following at the neck:
C2-C7 orientation in the transverse and frontal plane to the right, with compensatory rotation and sidebending to the left.
The OA joint is sidebent to the right and rotated left as a passive orientation.
The RTMCC may be present in isolation or with various cranial strains.
A cranial strain may occur if the left SCM sidebends the OA left within the RTMCC pattern. This compensatory movement occurs to attempt to reduce OA rotation and upper cervical strain.
If you weren’t sleeping during the biomechanics section, you will notice that this goes against Fryette’s laws. In order for this compensatory strategy to occur, the right alar ligament and posterior capitis muscle must become lax. This movement does help reduce torsion and compression on the upper cervical segments, but may create a cranial lesion in the process.
This compensatory movement is a precursor to a left sidebending cranial lesion, and this lesion along with others are quite prominent.
According to a 2008 study by Timoshkin and Sandhouse, 72% of individuals have a cranium that is in a sidebend or torsion pattern; with left sidebend and right torsion being the most common.
Of those two cranial strains, the left sidebend will be the most common. Let’s dive into that pattern more.
Left sidebend (LSB)
The LSB lesion is named for the sphenoid’s greater wing position. In this case, the greater wing is high on the right and low on the left. The occiput matches this orientation.
Where these bones will differ occurs about a vertical axis; as the sphenoid externally rotates while the occiput internally rotates.
The mechanical change at the atlas drives this position. The sphenoid just goes along for the ride.
A prime example of this cranial strain would be the lovely Garey Busey.
Right Torsion (RT)
RT’s also have a low left greater wing of the sphenoid, but the big difference is at the sphenobasilar joint.
Since the RT is a progression from the LSB, the occiput will attempt to sidebend right to level occipital position. Since the sphenoid stays in position, torsion through the sphenobasilar joint occurs.
This twist is driven by the sphenoid as means to create pseudo-facial symmetry via extension.
Lorimer Moseley is actually a perfect example of this type of cranial position, as many facial features are flipped from a LSB face.
This is a Test
The only way to truly determine which cranial strain one has is through imaging, but PRI testing can guide us down a treatment path.
Admittedly, the cervical tests are not the most reliable of the PRI bunch. To attempt to offset this limitation, we shall imply a test battery to determine position.
There are four essential tests in the TMCC algorithm:
Cervical extension: Checks cervical lordosis presence; goal is 30-35 degrees.
If limitations are present it is likely that SCM hyperactivity is reducing the normal lordotic curve.
I think of this test as the extension drop test of the cranium. It tells you if you are working with someone who is sagittally lax or not.
Cervical axial rotation: Checking C7-T1 rotation, which reflects C2 position. Looking for symmetry at about 30-35 degrees of movement. This test determines the TMCC pattern.
Limitations will be present due to the cervical spine’s compensatory rotation and sidebend to the left. Placing the patient supine on a table rotates the spine further to the left, which places a RTMCC patterned neck in an end-range position. Hence, normally left cervical axial rotation is limited. We would see bilateral limitations in a BTMCC.
When performing this test you want to make sure that you do not give the patient a lordosis, for this can create false negatives.
Midcervical sidebending: I think of this test as the great comparer between the cervical spine and the cranium. Looking for symmetry at about 30-35 degrees. This test gives you a frame of reference for our next test.
In the RTMCC pattern, this test is limited to the right secondary to an arthrokinematic block. If the cervical spine is rotated left on the table, the neck cannot sidebend to the right. That’s Fryette’s laws brah!
OA sidebending: This test looks at cranial position. Looking for 8-10 degrees bilaterally.
More than 10 degrees of sidebending would indicate alar ligamentous laxity.
A RTMCC individual would have limited right OA sidebending due to a bony block. In someone with a LSB however, you would have limited L OA sidebending because the left SCM pulls the OA over to the left. A RT could present with just about anything, as pathology is quite prominent in these folks.
RTMCC repositioning and retraining goes about the following progression:
Cervical spine → OA joint → Mandible
The neck is the top priority because its mobility maximizes cranial sensory activity.
Moreover, most cranial activities are integrated multi-joint movements. Spending time doing “basic” PRI sets the foundation for one to combine complex movements.
Mandibular movement is often normalized by the time the neck is cleared. The reason TMJ mobility may be limited because of craniomandibular discord.
In the RTMCC pattern, the right lateral pterygoid works with the right anterior capitis and right SCM to deviate the temporal bone and mandible to the left whilst the occiput (and sphenoid) are “stuck” in the left sidebend position. In a neutral system, we would expect the occiput and sphenoid to move to the right during this cranial movement. This tonal issue could limit mandibular movement.
Thus, a neutral cranium often restores normal TMJ mechanics. If problems still arise, then mandibular re-education may be necessary.
Sometimes you need a Dentist
Of the two common cranial strains, RTs will most likely need integration.
With normal occlusion, one side of teeth should touch while the other discludes. This alternation creates lateral shifting in both the mandible and the cranium.
The canine teeth act as guides for where the jaw ought to be in space. When canines touch during shifting, molar contact follows as the teeth drop into position. This action is called group function.
If group function cannot occur, it is likely that a dentist may need to be involved.
Splint therapy is generally recommended in these cases. More specifically, mandibular splints are the go-to (which I spoke about here and here).
Maxillary splints are generally the devil. These splints tend to increase tongue activity and mandibular clenching to hold the splint in. The one major case that may warrant a maxillary splint is the presence of tori.
Even if not using PRI splints, there are four essential pieces needed from a dentist:
Don’t lock the mouth into a position.
Move head back and jaw forward with canines.
Feel one side occlude while the other side discludes.
Have group function and anterior guidance between incisors.
Note – anterior guidance is when the incisors touch the molars disclude
You might be wondering how I educate people about this stuff in a nonthreatening fashion. I got this neat little tidbit from the Ronimal:
“Periodontal ligaments are so sensitive that a hair will throw off your gait.” ~ Ron Hruska
Think about that statement the next time you get something stuck in your teeth. Drives you crazy right? If there is something undesirable going on with your teeth, you will know about it in some way. Some output will occur.
Moreover, think about what occurs at the dentition when stressed. Do you clench? Reducing this muscle over activity by splint therapy introduces a salient stimulus that could reduce the stress response, if the craniocervical region is involved.
Hint: It usually is.
Infamous Ron Quotes
“Every single bunion and ACL patient is a TMD patient.”
“I love dentistry, but I don’t like dentistry, but I like dentistry.”
“You cannot treat a neck if a neck can’t treat itself.”
“We are a product of how we move our cranium.”
“A bra strap will really mess a tongue up.”
“The worst thing you can do to a patient is splint their neck.”
“We still have a lot of goniometric minds.”
“What good is the polyvagal theory if you don’t understand the neck.”
“Don Neumann is the best book for 1% of the population.”
“Treatment starts when you appreciate frontal plane.”
“How can you treat a TMJ if you can’t control the T?”
“The vehicle you drive is not the problem, it’s the path your on.”
“A twisted levator is an untwisted neck.”
“Hallelujah you have a pattern.”
“When you lose your left ab wall the head and neck will pick up the slack.”
“You can learn a lot about cognition and personality if you look at a neck.”
“You can’t feel CSF flow if you lack a cervical lordosis.”
“Make sense out of sense.”
“A neck that can’t move will produce a cant.”
“Crossbites, pulled bicuspids, and high arches scare me.”
“Sedentary lifestyle and screens demand we go straight.”
Back in April I had the pleasure of finally attending PRI’s annual symposium, and what an excellent learning experience.
The theme this year was working with high-powered, extension-driven individuals.
The amount of interdisciplinary overlap in each presentation made for a seamless symposium. Common themes included the brain, stress response, HRV, resilience, and drive. These are things altered in individuals who are highly successful, but may come at a cost to body systems.
If you work with business owners, CEOs, high-level athletes and coaches, high level positions, straight-A students, special forces, and supermoms, this symposium was for you.
And let’s face it; we are both in this category!
There were so many pearls in each presentation that I wish I could write, but let’s view the course a-ha’s.
The Wise Words of Ron
Ron Hruska gave four excellent talks at this symposium regarding high performers and occlusion. Let’s dive into the master’s mind.
People, PRI does not think extension is bad. Extension is a gift that drives us to excel. Individuals who have high self-efficacy must often “over-extend” themselves. This drive often requires system extension.
Extension is a consequence, and probably a necessary adaptation, of success.
If this drive must be reduced to increase function and/or alter symptoms in these individuals, we have to turn down the volume knob.
How can we power down these individuals?
Limit alternate choices – These folks take a wide view of a task
Set boundaries – These folks attribute failure to external factors
Making initial tasks successful – So these folks don’t give up at early failures
Objectively measure improvement – This helps motivate people to continue
Establish rhythmic activity that reflects specific set goals – the higher the goals the more likely the positive change.
A Tale of Two Forward Heads
We discussed a lot of attaining neutrality at the OA joint. What does that entail?
A: Both occipital condyles centered in the atlas fossa with unrestricted lateral flexion.
What is needed to have that?
55-60 degrees of cervical extension.
Equal bilateral first rib rotation position.
Centric occlusion with the anterior teeth guiding protrusive movement and canines guiding lateral movement.
Normal maxillary and mandibular teeth contact.
Ability to nasal breathe.
Alternating pelvic capability.
Normal hearing bilaterally.
Lose any one of these and a forward head posture may occur.
The two types of FHP we see include one with the atlas migrating forward with increased cervical flexion and occipital protraction.
And one in which the atlas migrates backward on the occiput in which excessive upper cervical flexion coupled with lower cervical/upper thoracic hyperextension.
With the former’s case, these individuals have a harder time feeling posterior teeth; a loss of frontal plane. When one loses frontal plane, the individual must attempt to increase anterior guidance via extension. Strategies used to do this include tongue thrusting, bruxism, fingernail biting, mouth breathing, clenching, etc. These strategies are protective in nature as they limit potential stress at the TMJ and OA.
Most of the latter include your bilaterally extended individuals. They retrude the atlas to significantly increase cervical stability. This hyperstability allows for dominant performance in the sagittal plane. These individuals may need more visual interventions.
She’s a Wise Woman
Dr. Heidi Wise gave one of my favorite presentations of the symposium. She discussed vision’s role in extension-driven individuals.
Vision is the most dominant sensory modality, as it has the ability to override all other senses to redirect attention. To me, this is why vision is such a powerful way to get someone neutral.
Redirection of attention through the visual system occurs through saccades. These eye movements occur 85% of the time our eyes are being used. This is how the visual system detects a salient stimulus.
If visual processes hold someone in an extension pattern, it may become extremely difficult to near-impossible to overcome.
Here is how we start thinking a visual process may be promoting an extension pattern:
Those who cannot inhibit extension with traditional floor-up activity.
Late-onset (past puberty) or severe near-sightedness.
People with extremely good eyesight.
Folks who over-focus on objects straight ahead (people who stare).
People who walk with purpose (makes me think of my mom in the mall!).
If someone over focuses (read: nearsighted), eye exploration is minimized. It becomes much harder to notice change, or salience. This is how the visual system can keep someone stuck in a stress response.
What is needed to see close?
Increases in acetylcholine and norepinephrine.
Reflexive increase in neck/head muscle tension. More so if one must strain to see.
Do this too long, and we can see unfavorable autonomic, visual, and neuromuscular stress.
And guess what visual field research is showing we better attune to? The right side; more specifically, the right upper visual field.
The PRI goal? We want to restore ambient vision in these individuals to process three planes of visual motion.
Here were some of Heidi’s recommendations for how to do so.
Take breaks from a task to move.
Be aware of surroundings on both sides without looking when walking.
Walk slower than usual.
Look around using your eyes independent of your head.
If nearsighted, take glasses off occasionally and “be OK” with things far away being blurry. Don’t strain to see well.
Have top of computer screens at about eye level. Look far from the screen as often as possible.
Close eyes and visualize a large open area that makes you calm.
Minimize time on small, close screens and keep object far from eyes.
Read books over e-readers and keep the book as far away as visually comfortable.
Emphasize peripheral awareness before and after high attention tasks.
Change variable such as sounds or environment during high attention tasks.
Strongest memories are tied to emotions; more negative than positive.
If the limbic system is too active (such as in a threatening environment), prefrontal cortex activity goes way down. You can’t learn as well.
Cranial nerves are extremely important in social interaction. Nonverbal cues from these areas can unconsciously affect autonomics.
During adolescence (12-25) the right side of the brain and limbic system develop faster than the left and neocortex. This lateralization is why this time period can be so emotion-driven.
Face to face interaction is needed to cultivate the nervous system. This is the problem with social media and texting.
Dopamine pathways are very active during adolescence; it’s one of the reasons addictions start during this time.
Feelings of being overwhelmed are 6 times more common in those who have had concussions.
Rehearse making mistakes and how you will come out of them.
He also provided some great patient interaction nuggets that I hope to liberally steal.
Keep your eyes on the individual and tell them “it’s great to see you here.”
If you are not doing well on a given day – “I don’t feel good today but we’re going to have a good session.”
If you are at odds with a patient – “We’ve seemed to come to a roadblock. Would you agree?”
My big takeaway from psychologist Dr. Tracy Heller’s talk was mindfulness.
Mindfulness is something I am hoping to get more into in the future. She defines it as being aware of your thoughts, emotions, physical sensations, and actions in the present moment without judging or criticizing yourself or your experience.
It’s a big deal to have this capability. Practicing mindfulness has been shown to reduced cortisol, stress, pain, depression, and anxiety; while also improving memory, sleep, and cognitive function.
The way we build mindfulness is basically letting go. I like the analogy that I heard while using Headspace (a great app if you haven’t used it). Imagine your thoughts and feelings as cars in traffic. Your goal is to just watch the cars pass by, not chase them. You want to be present in the moment, as we want in most of life.
One option of practicing this is resonant frequency breathing, in which we perform 4.5-7 breath cycles per minute. Let the body breathe on it’s own and let the air come in; using terms such as “let,” “allow,” and “permit.” These are cues I have been using much more with patients and has made a big difference.
This was easily my favorite part of the symposium (I may be biased since my Dad gave this talk). Bill Hartman blew it out of the park teaching us how PRI applies at the highest level of performance.
The rules change in the performance realm because the patterns are incredibly powerful, effective, and efficient. In some cases we may want them. A perfect example that Bill gave: Usain Bolt
Rarely does he cross midline when he runs, making him the fastest runner on one leg. Do we want to change that? Probably not.
Performance does not equal health. Gymnasts for example, may need to create pathology to perform at a high level. Some people must utilize passive elements to produce greater outcomes. Usain Bolt runs on one leg. Everyone is a case-by-case basis. N=1 forever.
What must occur in the performance and health realm is stress management. Acute stressors with recovery make us antifragile; prolonged stressors reduce variability as an allostatic adaptation.
If one must constantly perform at a very high level, where will they be on this stress dichotomy? Prolonged stressors = reduced variability, sympathetic dominance, and system extension.
Variability helps us anticipate demand. It helps us become better able to cope with specific environments and recover movement function. The only way we can know if movement variability is present is through assessing the musculoskeletal system
“The state of the musculoskeletal system is the other end of the brain” ~ Bill Hartman
If stressed or threatened, body systems use default reflexive mechanisms to combat threat. The brainstem is much faster than the cortex. As a consequence, variability can be lost.
Attaining increased prefrontal cortex activity allows us to inhibit our default response and increase variability. That’s why mindfulness increases HRV, and that’s why a 90/90 hip lift can alter body position.
To better manage stress, we must train. Training is a progressive desensitization of threatening input to allow an athlete to perform at adaptive potential with optimal variability and without fatigue.
The higher performance level required, the more difficult it becomes to get neutral. This is what happens during functional overreaching. You gain higher performance output during this timeframe because the sympathetic nervous system and HPA axis are on overdrive.
Applying Bill’s principles along the training and rehab continuum, rehab requires neutrality and variability to rebuild a failed stress tolerance. The amount needed in performance realm will depend on how (in)variant one’s sport is.
The Wild World of Combat
Dallas Wood and Zach Nott work with in a military population, and it was fascinating showing how they mitigate the extension necessary for their clientele to perform. They guys collect a lot of data, and the fun factoid was that about 80-90% of their individuals are PEC and bilateral BC (surprise surprise).
They showed us a very cool auditory case. They had a dude with a PEC/BBC presentation with a history of ear trauma and tinnitus. When they blocked his left ear the gentleman was completely neutral.
Treatment underwent reducing the tinnitus by implementing a hearing aid that uses various white/pink noises to slowly reduce tinnitus. Not sure exactly how it works, but this was exciting to hear about (ha). I look forward to learning where PRI takes auditory integration.
So there you have it. I already signed up for next year’s symposium because this one was so much fun. I look forward to more of the consistently fantastic content that PRI provides. Learn on!