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.”
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.”
I recently made the trek to Vermont for the first rendition of PRI’s Cervical Revolution course; a course in which the attendees doubled the population of the entire state.
It was nice to go to the class with a bunch of old friends. You always learn better that way, and I couldn’t have been more excited to get the band back together.
And even more so, I got to meet a lot of good folks for the first time. It was a real treat.
This course was meant to update the former craniocervical mandibular restoration course (which I reviewed here and here), with extra emphasis on the cervical spine and OA joint.
In this blog however, I will not touch much on the cervical spine positioning. I still have several questions regarding the mechanics. Some spots within the manual seemed to be conflicting; the blessing and curse of a first run-through. I will update this piece once I get these points figured out.
That said, the revolution helped fine tune the dental integration process for me. I have been working a bit with a dentist, and I have a bit more insight in terms of what devices they are using for whom.
Let’s go through my big a-ha moments.
The human body is symmetrically asymmetrical. When we have capacity to alternate and reciprocate, we are able to separate the body into parts to form a whole.
If you lack integration, then there are no parts. You have an it. This is how somatosensory smudging works. Lacking parts creates a pattern. A pattern could create a threat to the system, or a threat to the system could create a pattern.
We need to be able to differentiate our parts.
Neck Problems Do Not Exist
The craniocervical region is incredibly mobile for a reason. That reason is to create precision for our sensors: vision, audition, olfaction, respiration, and vestibular sensation. This precision occurs reflexively, whereas other appendages act proprioceptively.
These sensors drive the neck. Losing the ability to sense is what can increase the need for a neck to become stable. And when you can’t move a stable neck, teeth may be one thing you try to use.
In this course, the sensors we focus on are our canines and molars. Canines are transverse-plane antennae; necessary for lateral guidance. Molars, on the other hand, let us know what side we are on (frontal shifting).
Two TMCC Possibilities
Ron spent a much greater amount of time discussing two patterns that were briefly mentioned in previous courses: the left sidebend and right torsion.
These two patterns are possibilities that can occur at the cranium in a right TMCC pattern; and it all depends on what happens at the sphenoid.
The Left Sidebend
The left sidebend pattern is typically what we think of with the RTMCC. The atlas is rotated to the right, the occiput rotated to the left, the sphenoid oriented to the right, and the mandible oriented to the left. This positioning cants the mouth left and upward; creating a counterclockwise facial rotation.
It looks like this:
Test-wise, these individuals are limited in cervical sidebending to the right and axial rotation to the left.
Treatment will consist of developing left sided awareness, especially of occlusion. We want left abs to coactivate with a right SCM to establish neutrality. Here is the base repositioner to do that:
Here is where things get a little crazy. In these individuals the atlas, sphenoid, and mandible are right oriented; with variable positions occurring at the remaining cranial bones. This creates a right mouth cant and a subsequent clockwise facial rotation. This cant begets an over-referenced right sided occlusion which can become difficult to move out of.
It looks like this:
Test-wise these individuals will have bilateral limitations in lateral flexion, yet left axial rotation alone shall be limited.
These individuals will likely need some dental integration due to the over-right lateralized cranial positioning; many of these folks have had craniocervical trauma.
Therapy treatment will involve alternating activity, and here is our repositioner for that:
Splints on Splints
One of the big reasons I took this course again (aside from having a con ed problem) is because I wanted to really iron out who ought to get what splints. I definitely learned a much better appreciation for each splint type PRI recommends, and it was nice to see what new stuff they are using. Here are the big ones.
The PRI MOOO
This splint is the new one PRI is making, which is similar to your typical flat plane splint. The big difference is the anterior portion of the splint is built up to allow for better canine reference. Canines are what allow an individual to twist and turn, so the better we can feel these guys the better triplanar capabilities we will have
Who gets it: RTMCC folks; those who have a hard time finding teeth, more neurologically unstable folks.
The Gelb Splint
This guy is the one I was given. This splint helps bring the mandible slightly forward, creating better craniocervical mobility. There is also a lingual bar to reduce tone on folks with active tongues.
Who gets it: Individuals with narrow bites, active tongues, people who talk a lot throughout the day, one who can protrude the jaw forward, disc issues. Generally people who are fairly stable will get these, as they allow for much more movement freedom compared to the MOOO. Makes sense now why I was given this as I had no patho-compensatory patterns.
This device helps retrude the cranium to improve an airway and is usually worn only at night.
Who gets it: Right torsion patients, those with discal compression, individuals with sleep apnea, prophylactically.
These are the expensive beasts. It is an appliance that is worn around the maxillary and mandibular teeth to promote maxilla expansion and cranial flexion. You will likely need orthodontics after this one, as the teeth have a tendency to move.
Who gets it: Individuals with high palates (bilateral or unilateral), individuals who are very neurologically unstable, excessive disc popping.
So there it is. While it had the first-run bumps, this course’s information is priceless; necessary to truly integrate PRI to it’s fullest potential. Attend, find yourself a dentist, and help some people.
Infamous Ron Quotes
“There is a lot of feet in your mouth.”
“Foramen magnum is life.”
“Upper trap is a thermostat.”
“I want to twist the hell out of you so you can untwist and enjoy life.”
“You will never develop abdominal obliques without lateral pterygoids.”
“Dysautonomia is a bad ebola.”
“I’m no different than your protoplasm.”
“If you like feet you gotta like neck.”
“That’s called vagal sciatica.”
“Is it okay if I produce and Arnold Chiari syndrome on you?”
“The best physical therapists are ones who integrate with other disciplines.”
“The best sensory organ you have is your teeth.”
“Cervical revolution is a gift.”
“If you don’t like your spouse give them a NTI.”
“A hyoid that’s high is a cranium that’s forward.”
“You stretching out a neck is not going to get a cranium to go back.”
“The worst thing you can say to a patient is don’t do it.”
“There is no effectiveness in treating a symptom.”
Mike Cantrell was in my neighborhood to teach Myokinematic Restoration by the folks at PRI.
And I couldn’t resist.
This is the third time I have taken this course, a course I feel I know like the back of my hand, yet Mike gave me several clinical gems that I want to share with y’all.
This post is going to be a quick one. If you want a little more depth, take a look at my previous myokin posts (See James Anderson and Jen Poulin). Or better yet, take a PRI course for cryin’ out loud.
Hip Extension, We Need That Yo.
Sagittal plane is your first piece needed to create triplanar activity. Since this is a lumbopelvic course, we look at getting hip extension as high priority.
If I am unable to extend my hip, here’s what I could try to use to do it:
SI joint compression
Anterior hip laxity
Gastrocnemius and soleus.
We use two tests to see if we have hip extension: adduction drop (modified ober’s test) and extension drop (Thomas test).
The adduction drop will look at your capacity to get into the sagittal and frontal plane, and the extension drop test will look at your anterior hip ligamentous integrity.
A positive extension drop is a good thing if you are in the LAIC pattern. It means you didn’t overstretch your iliofemoral and pubofemoral ligaments. Well done! The reason why this test is not a hip flexor length test has to do with the femur’s position. In the pattern, the femur is positioned in a state of internal orientation secondary to an anteriorly tipped and forwardly rotated pelvis.
Due to this orientation, the femur must be externally rotated during performance of an extension drop test. This would put the psoas on slack. If you still have a positive test, then we know the anterior hip capsule is intact because that’s the only thing holding the hip up.
We spent a good portion of the day learning about gastrocs. In the LAIC pattern, the right gastroc runs the show as a hip extender AND hip external rotator.
The slight inversion action that the gastrocneumius performs helps pick up the transverse plane slack that the right glute max is malpositioned to do so. This is why the right calf is usually larger than the left.
This test’s pinnacle is the 5/5, to which gives us ground to become alternating and reciprocal warriors.
Just because you can hit 5/5 on both sides does not mean you can alternate well.
I was a prime example in class. Mike had me demonstrate my HAdLT in class, to which I easily hit 5’s on both sides.
Despite my quest towards neutrality, I have not been able to keep good thorax and neck positioning. Thanks wisdom teeth.
So Mike checked my right shoulder internal rotation, to which I had about 70 degrees. Way better than the previous 10 or so degrees I started at.
Then Mike had me perform the left HAdLT, which pushed me into my right hip.
Shoulder internal rotation worsened to 30 degrees.
He then pushed me into my left hip with the HAdLT.
Shoulder internal rotation now 90 degrees.
Even though I can crush the lift test, I do not alternate well because I lose position at other areas.
To truly be an alternating and reciprocal warrior, one must be able to perform alternating activities without losing position anywhere in the body.
Why Can’t I Swing my Right Arm?
In many folks with a LAIC/RBC pattern, you will notice that there is minimal right arm swing. You would think that the right arm would be activity secondary to right lateralization and hemisphere dominance. Not necessarily so though.
Arm swing is dependent on trunk rotation. If the trunk can rotate, then the arms can swing.
In the pattern, it becomes very difficult to rotate the trunk to the right, which mean there is no need for right upper extremity extension. So how about instead we just plaster the arm the side? Not a bad idea.
Crazy Good Cues
To close, Mike is a cueing machine. I picked up three new favorites that we’ve been playing around quite a bit in the clinic.
Press heels down on a chair to decrease TFL. Don’t use a ball because the TFL will attempt to adduct the femur via internal rotation. Then slowly add the ball.
Sigh upon exhalation if you have a patient who is rectus-dominant.
Plantarflex the first big toe to feel the left IC adductor in standing.
“Orthopedic symptoms are the result of bad neurology.”
“Good posture compromises respiratory dynamics.”
“Think before you stretch.”
“Stretching is the equivalent of kicking a horse while pulling on the reins.”
“99% of righties have a left thing.”
“Doesn’t matter what the diagnosis is.”
“Give me sagittal or give me death.”
“Most strength deficits are motor control deficits.”
“Total arc depends on what moment in gait you are in.”
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.”
The first Section Where I Usually Say Something Like Whew or This Was the Best Course Ever!
Phoenix has yet to disappoint on the CEU front, especially if the Dbacks are hosting. What a facility!
After the baseball course that my homies Allen Gruver and James Anderson taught, Ron and Heidi put together a small vision course that one could apply on baseball athletes.
Only it was so much more than advertised.
Whether it was intended or not, the dynamic duo demonstrated just how extensive the PRI principles are, and spoke to many of the neuroscience foundations to which it was founded on.
PRI Vision Integration for the Baseball Player was the Batman Begins of PRI.
I am going to tell you right now, you must take this course yesterday. The foundational science alone is worth the price of admission, but adding in the visual training and corresponding life lessons, you get way beyond what you expect.
Here were the major nuggets that I picked up.
GGGGGG-rav…a…ty (Said as though 50 Cent read the title)
Two major forces are acting upon a body at all times: gravity and ground.
When one is able to manage and be aware of these forces, alternating and reciprocal triplanar activity can be realized. This reason is why PRI emphasizes finding the floor and feeling grounded so much.
When these forces go unrecognized within a human system, extension is needed to maintain uprightedness.
For example, do you ever notice that some individuals look at the ground when they walk? Why do people use a strategy normally reserved for peripheral vision? PRI would argue that because a body does not feel its connection to the ground, so the visual system is utilized to observe that this is happening. The eyes perform the task that the feet ought to do.
If the eyes begin taking over to help one remain upright then you are going to have reduced input from your other senses. This ain’t a good thang!
Round One: Sight vs. Vision
Sight is only a small piece of visual process. It involves the extent and clarity of one’s visual field.
Each eye is capable of achieving 20/20 vision, which means that objects seen at 20 feet away appear clearly as though they are being viewed at 20 feet. To contrast, someone with 20/10 can see something 20 feet away that a 20/20 person must see at 10 feet.
Most baseball players at the pro level have 20/15 or better.
20/20 or better is encompassed in the macular visual field, to which details are picked up. Focusing in this field creates the most stability through extension. Only 3% of your visual field is here, yet this area gets all the love from people
The remaining 97% of the visual field is peripheral. Color and clarity is lost, but this field is the best place to pick up motion. Hanging out in the periphery also creates the most system instability. It is your frontal and transverse plane.
Vision, on the other hand, involves outputting meaning and action via radiant energy input (i.e. light) through the retina.
The perceived visual picture is only a small portion of vision. 70% of the sensory information in the brain is visual, and there are many unconscious processes that occur by radiant energy input.
The visual system has so much sensory power that it can and often does override information from other senses.
Round 2: Sports Vision vs. PRI Vision
Sports vision allows an individual to maximize extension and sympathetics; a critical piece for performance. It is visual system weight lifting.
These skills involve training visual acuity, eye tracking, focusing, coordination, central-peripheral integration, and depth perception. All of these skills are necessary for the highest level of performance.
PRI vision training differs because it involves managing gravity, ground, and bodily awareness without visual overutilization. PRI vision is visual system recovery.
Skills needed here include knowing where one is in space, being able to center over each leg, and combining vision with other sensory information.
Integrating these two types of skill training allow one to maximize and recover from desirable performance output. That said, performing sports vision training on an extended system could be disastrous.
Mad PRI Vision Integration Skillzzz
Being able to visually alternate between power and relaxation is of utmost importance in PRI vision training. This is autonomics. This is breathing. This is life.
We can relate the three skills taught in this course to breathing. When we are in a state of inhalation, we are sympathetic and power-driven. When are in a state of exhalation, we are parasympathetic and recovery-driven.
Our 3 skills include:
Visual focus (inhale)/Visual relaxation (exhale)
Central vision awareness (inhale)/peripheral vision awareness (exhale)
Eyes moving with the head (inhale)/ eyes moving independent of the head (exhale)
Let’s look at each a tad more in-depth.
Round 3: Focus vs. Relaxation
Focusing requires head, neck, and eye tension to see any object closer than 20 feet away clearly. This tension is normal; it gives us power and is necessary to perform at a high level in many sports.
But think about what an athlete individual does when off the field not performing? How many people are on phones or other screens most of the day? To be on these screens require over-focusing; constant tension. When we have constant tension without ever giving our visual system time to relax, we run into trouble.
When we see near-sightedness worsen, which technically doesn’t truly set in until teen years, we have a problem shutting off our visual system. We have a problem with recovery. We have a problem with having less.
Relaxing visual focus can inhibit these tendencies and promote visual recovery. We can use this basic principle in any activity:
Focus on an object that is 5 feet away or closer.
Find an object that is at least 15 feet away.
Alternate looking at the two.
The farther one can see clearly with relaxation, the better one is at inhibiting the visual system.
Round 4: Central vs. Peripheral Visual Awareness
This training emphasizes using the correct visual field at the desired time. When distractions must be reduced, such as a pitcher aiming his pitch, central vision should be utilized. A pitcher simultaneously aware of a player on first base and the catcher uses both central and peripheral. In the baseball world, there is almost never an instance when peripheral vision is dominant.
The right-sided human norm involves greater right peripheral awareness. Right space appears to be more open than left. To maximize visual relaxation, we want the ability to perceive both left and right periphery.
If the brain does not recognize peripheral space, then the ability to shift and rotate is reduced. There is no need for action in space that cannot be perceived. Thus, accessing peripheral awareness allows for increased transverse plane movement freedom.
The easiest way to increase peripheral visual awareness is to just be cognizant of your surroundings or working in environments that have a lot of motion.
Round 5: Eyes with head vs. Eyes without head
Saccadic movements are the big player here. These movements involve changing fixation from one point to another; using only the eyes. This eye movement is used throughout everyday life, and is commonly done so in a left to right fashion.
Every time you read a book you use saccades to do so.
Keeping the eyes moving independent of the head is easiest when the distance between fixation points is small and the eyes are not pushed toward extreme end-ranges of motion.
Baseball requires use of these extreme end ranges; thus requiring the eyes and head to move as a unit. This strategy will increase sympathetic drive, tension, and performance.
We don’t want this style while you are sitting on the couch.
Here’s how we do it
1. Pick 3 points at various distances. Moving eyes only, look right 30-45 degrees–>straight–>left 30-45 degrees.
2. Pick 3 points at various distances and look at something 30-45 degrees below midline –> straight –> 30-45 degrees above midline
3 Pick 3 points at various distances and tilt head up, keeping eyes on target 30-45 degrees below midline –> midline –> up
Seriously, Stop Talking About Reference Centers
I can’t. Just can’t get enough of these things.
Especially since I had a huge revelation on these this weekend. It started when Ron made this comment:
“The ball in any game is a reference center.”
Say what? Here this whole time I was thinking of reference centers as inputs within us that help facilitate a pattern.
But they are so much more than that.
A reference center is any sensory input that facilitates a change in positional output.
Take the ball example. When an athlete sees a ball, that object is a sensory input that is going to prime their systems to play the sport. Often this results in necessary extension.
Ron illustrated this point several times in class. One of my classmates who used to pitch was given a baseball and instructed to assume the pre-throwing position while focusing on a target.
He was stable, primed, and by the look on his face ready to throw that ball as hard as possible.
Put him on the table and check is shoulder mobility, and he went from about 30 degrees of IR to 5, 30 to 10 horizontal abduction, and a large drop in flexion.
The ball cued him into extension, as that reference center gave him power.
Then Ron did something that was utterly fascinating. He taped the ball with black kinesiotape and had him get in the exact same position.
When he first grabbed the ball, you could tell he wasn’t really sure what to do with it. He got into the pre-throw position a bit calmer but was also more unstable.
Ron then put him back on the table, his shoulder motion now was 80 degrees IR, 50 degrees horizontal abduction, and full flexion.
Simply changing the context led to large changes in outputs. Everything matters.
Think of all the reference centers a baseball player could have that could keep him extended:
Since players are not getting rid of all these things between plays, how can one expect to shut down and recover?
An interesting suggestion was to take away one reference at a time until neutrality was achieved, then perform PRI activities (including those listed above) until one could maintain desirable position. Slowly, you would add more of these pieces.
Retraining in this capacity could possibly allow for an athlete to have improved recovery between plays.
There it Is
I can’t emphasize enough how much I liked and how important this course was for me on many levels. You will definitely not regret attending this; whether you are a PRI vet or rookie.
Now for the important stuff.
Infamous Ron Quotes
“There’s baseball and there’s China.”
“The ball in any game is a reference center.”
“If you look at the ball and don’t know where you are at you will miss that ball.”
“I’m just trying to psychologically twist you.”
“If you look at the ground to get the ground you are ungrounded. And Zac you can tweet that!”
“Now if he wasn’t positive I’d create it.”
“A successful process means you need less.”
“The more they can learn to turn it off the more they’re capable of turning it on for better outcomes.”
“He’s sympathetically a sunflower seed chewer.”
“If you don’t recognize you have tension you can’t turn it off.”
“Extension activity is good if you season it with peripheral activity.”
Very Wise Heidi Quotes
“It’s not the eyes that the problem is in. It’s the brain.”
“Nothing will destroy a program faster than looking at the ground.”
“Extension is needed for gravity and ground.”
“Mismatch is mandated by neck function.”
“The human body was made to observe peripheral movement.”
You’d think, but CCM is one of the hardest PRI courses to conceptualize.
It didn’t hurt that my work was hosting the Ron’s last time teaching this course, as next year we will see Cervical Revolution instead.
I took this course last February, and it’s amazing how different the two courses were. We had a room filled with PRI vets, and the Ronimal went into so much more depth this time around.
It was such a great course that I would love to share with you some of the clarified concepts. If you want a course overview, take a look here.
The right TMCC pattern consists of the following muscles with the following actions:
Cranial retruders/mandibular protruders
Right anterior temporalis
Right medial pterygoid
Left rectus capitis posteror major
Left obliquus capitis
OA flexors that maintain appropriate cervical lordosis
Right rectus capitis anterior
Right longus capitis
Right longus colli
If this chain stays tonically active, then there is better accessory muscle respiratory capacity present. These muscles provide the fixed point needed for an apical breathing pattern.
We want the muscles on the other side, the left TMCC, to be active. Their activity will allow alternating reciprocal cranial function to be possible.
We also call this gait.
Keep Ya Sphenoid Flexed
One cranial goal we have is to achieve sphenobasilar flexion, but what does this mean?
In the RTMCC pattern, the sphenoid is in an extended position. When the sphenoid is extended, the foramen magnum becomes larger and the spinal cord descends. This positioning explains all the chiari malformation jokes that we like at PRI-land.
This position would also create a forward head posture to create a compensatory airway. Consequently, occlusion may be altered.
The goal is to flex the sphenoid, which closes the foramen magnum and produces appropriate OA extension. This position keeps the brainstem happy.
Lordosis is Important
When the SCMs are overactive, especially on the left, a reversed cervical lordosis can occur.
If I see someone who cannot flex his or her neck, I’m not thinking of stretching them into flexion. I’m thinking about restoring cervical lordosis. If no cervical curve is present, then the neck is already at end-range. Stretching farther in this position could create potential pathology.
Lordotic position is achieved by the deep neck flexors listed above and maintained by a twisted levator scapula position under a foundation set by an active lower trap.
I learned to appreciate the SCM much more at this course.
In the RTMCC pattern, my OA joint is sidebent to the left. This position occurs due to the left SCM, rectus capitis lateralis, and levator scapula.
When an active left SCM is present, we usually see a corresponding frontal plane positional tug occur at the thorax and pelvis. Left SCM often works with the right quadratus lumborum and right adductor to push the sphenoid, sternum, and sacrum into a right lateralized state.
Pterygoids = Money
When lateral trusion in protrusion is assessed, we are not really assessing jaw mobility but pterygoid function.
The left lateral pterygoid moves the mandible anterior and to the right no doubt, but it also moves the cranium posterior and to the left. We call this left acetabulofemoral internal rotation aka shifting into your left cranium.
This Really Bites
We discussed a lot about bites this weekend. One bite that would most certainly need dental integration is an anterior open bite. This bite is when the front teeth are unable to contact due to a very high palette.
This bite type would be the equivalent of rib flares on a PEC individual. When one has an open bite, the mandible retrudes far enough to increase pressure onto the mandibular condyles.
The TMJ essentially begins to act like a molar.
We also got to see an individual with a cross bite, in which the part of the teeth go so far inward that teeth contact occurs at an angle.
This positioning is very similar to the feet in a left AIC pattern. The right foot is in a supinated position, but the first ray will oftentimes create first ray plantarflexion to touch the ground. A cross bite is a similar phenomenon.
Other Fun Clinical Tips
The louder and earlier the click upon TMJ opening the healthier the joint is.
Front teeth contact keep temporal bones alive.
Back teeth keep head from going forward.
(in)Famous Ron Quotes
“I’m not interested in your 45 mm of opening.”
“I’ve learned one thing in life. Jaw surgery does not work.”
“I call it the quadratus eboli.”
“We’re going to talk about sciatica of the head.”
“You know, my mother is not so bad after all.”
“I want you to take this course because this is life.”
“I’ll say feeling cerebrospinal fluid is a bunch of you know what.”
“If you’re a mammal you suck. You suck as a mammal.”
“If you don’t suck you don’t have a neck.”
“Are you a mammal? No Zac you’re weird.”
“The IC lateral pterygoid. Oh sorry wrong course.”
“You didn’t know getting your IC adductor would help you taste Pepsi better?”
“Guess I’ll go to PT school. Maybe I’ll learn something there. NOPE!”
“The best thing you can do is invest your retirement dollars on CPAP machines and ambien.”
“The system knows everything.”
“This patellar, excuse me, temporalis region.”
“Buy some Bose headphones and listen to Lady Gaga. Wow! That worked.”
“I just walked you through evidence that has been there for years and no one can handle it. Oops.”
“Surely. Don’t call me Shirley…Sahrmann.”
“I’m not here to recapture someone’s disc…Oh but I am.”
“The biggest shim that anyone does is a heel lift and it makes me want to puke.”
“If you have one foot that pronates and one that supinates, you’ll need a podentist.”
“The number one concussion is the Iphone.”
“Salt, pepper, and left lateral pterygoid.”
“I want his pube to like his malleolus. Oh I didn’t mean that.”
I made my first trip back to my roots since moving out west to watch Mike Cantrell’s version of one of my favorite courses: Impingement and Instability.
Yes, if you are wondering, my family does hate me for not being able to visit them.
Mike absolutely killed all of the various topics we covered, and his ability to coach some of the advanced PRI activities is second to none. I had a blast learning from him.
I won’t go over all the nitty gritty like I did here, but here were some of my favorite concepts that we covered.
The I&I Conundrum
Impingement occurs due to the human system’s conflicting demands.
We face a battle between instability and stability. Flexion allows for movement variability, which is desirable in the human system. Variable movement reduces threat perception.
However, system flexion leads to increased instability and the risk of falling forward. To combat this risk, impingement may occur by compensatory extension. Extension begets joint and system stability, yet system variability is minimized. Increased stability is desirable when under threat, but not for long term.
The “goal” then, would be to build control within flexed instability so the system can stay variable; to remain upright without extension. As Charlie Weingroff would say, we want “control within the presence of change.” That is alternating and reciprocal movement.
That doesn’t mean you have to do silly little PRI exercises for the rest of your life. PRI activities are simply neuromuscular training tools that help differentiate left vs. right to create system variability. Graded motor imagery’s laterality training does the same thing, albeit at the most rudimentary level. PRI is a progression from that.
Once we develop triplanar awareness, all we need to do to maintain system variability is continually reinforce variable position throughout the day.
Reference is the Key
The way we can remain upright without impinging into extension is to develop interoceptive and exteroceptive awareness of stability points in system flexion. More specifically, stability points created in left stance.
The name of the game is reference centers, which keep a flexed system upright in the environment. These centers allow one to engage the opposition muscles necessary to achieve left stance. In neutrality, reference centers give us control in the presence of change.
If we lose a frame of reference in flexion, then we lose stability. If we lose stability, we extend to become stable. If we extend to become stable, we impinge to create reference.
I&I mentions six official reference centers that send us into the RAIC/LBC pattern. However, there a several different ways we can create a reference. I’ll list the sweet 6 as well as a few others that were mentioned:
Right medial longitudinal arch when in left AF IR – Gives us right glute max
Left posterior (center) calcaneal tuberosity – Gives us left IC adductor
Left Ischial tuberosity – gives us left hamstring
Left anterior acetabular femoral capsule/right posterior hip – Gives us left stance
Left IO/TA/left posterior ribcage – gives us exhalation and a ZOA
Right lateral posterior upper ribs and right scapular when in left AF IR – gives us inhalation within a state of flexion.
Right lateral knee – Gives us right glute max
Tongue on the roof us the mouth – Pressurizes maxillary arch (aka mouth diaphragm) and relaxes neck musculature.
Left molars – Equivalent of left calcaneus.
Right pisiform – Your hand’s calcaneus. Feel this in the closed chain to get a right serratus.
Left index finger – to create an arch in the left hand; allows for grasping objects.
If one cannot find these references, one will right lateralize. The left AIC/right BC pattern is the norm. We are biased to be right dominant, and it is a way for us to maintain some semblance of stability.
There are several ways that individuals attempt to compensate for this bias. Some do nothing, some develop the capacity to alternate and reciprocate, some become left handed, some increase extensor tone to PEC levels.
In most cases, becoming alternating and reciprocal is desirable.
I Finally Figured Out the Foot a Little Better
The foot was somewhat of an enigma for me, even after taking I&I previously. Here is the lowdown.
In the LAIC/RBC pattern, the right foot is in a more supinatory position with calcaneal inversion; the left foot is pronated with an everted calcaneus.
These foot positions can create hallux limitus in both big toes for different reasons. The right big toe can be limited via active insufficiency if the first ray plantarflexes to touch the ground. This position would be a “deficit” equivalent to a decreased left straight leg raise secondary to an anteriorly rotated innominate. This compensation would also create a larger gap between toes 1 and 2 via abductor hallucis.
The left big toe is limited by passive insufficiency secondary to a pronated foot. The first ray is dorsiflexed because the foot is pressed into the ground.
Restoring big toe mobility must therefore follow a different progression than simply mobilizing great toe extension. The first line of business is to stabilize the calcaneus. If the calcaneus is moving all over the place and cannot adequately contact the ground, stability has to occur somewhere. Oftentimes this will occur at the mid to forefoot, promoting the aforementioned foot position.
We can create calcaneal stability via gastrocnemius inhibition to allow the heel to touch the ground:
[Side note: That squat was barefoot without my gelb splint or glasses. You have no idea how monumental that is for me.]
If your heels cannot touch the ground, you will never access frontal plane. If someone keeps losing hip extension or adduction in standing, think gastroc inhibition.
Then, we can create stability with good shoewear. Look for a stable heel counter as my Dad demonstrates below:
A stable calcaneus is needed because hindfoot position controls what occurs at the forefoot. The subtalar joint unlocks the forefoot during eversion and locks it during inversion. Foot intrinsic strength becomes meaningless if you can’t control frontal plane calcaneus movement.
Take that into account if you are a barefoot advocate. I’m totally cool with the idea of barefoot training IF you can stabilize your calcaneus and are not driven further into extension with your shoes off.
Once we have a stable calcaneus, addressing first ray position becomes critical. Oftentimes the first ray is good once you have the calcaneus, but if not we may need to build up the arch in the shoe or throw in some classic manual therapy to alter position.
Foot position can be extrapolated by testing hip abduction and adduction movement. If there is limited abduction, chances are an individual is overpronating. If the adduction drop is positive even after gastroc inhibition, there is likely a supination restriction.
If you perform the above steps and there are still big toe extension limitations, then big toe-oriented manual therapy sounds like a wise choice.
Some Neat TMCC Side Discussion
You ever wonder why people stick out their tongue when performing a challenging activity?
It has to do with tongue thrusting. One thrusts the tongue forward to create OA and neurological extension. This maneuver would help increase extensor tone, leading to improved force production.
It’s probably not a good idea to do that all the time.
Many individuals with a narrow palette, and thus a narrow airway, require palatal expansion. We want the maxillary arch to look like a U more so than an A.
When we look at how to expand the palette, there are several different devices that can be used; ranging from most aggressive to least aggressive:
Rapid Palatal Expander (RPE): this is where you turn the key to expand the palette. = Bulldozer knocking down a tree.
Herbst appliance = car chained to a tree.
Alternative lightwire Functional Splint (ALF): Spreads the palette 2mm to reduce muscle tone. = A person holding a tree.
Tongue on the roof of a mouth = Dog peeing on a tree.
Hip Impingement Help
Walking should allow for desirable acetabulum on femur (AF) and femur on acetabulum (FA) movement in three planes.
AF adduction ought to occur from foot strike to midstance, and AF abduction from midstance to terminal swing. The hip also progresses from external rotation to internal rotation up to midstance, then back to external rotation until terminal swing.
If these joint positions cannot be achieved secondary to the pattern, nociception from the hip joint can be produced by impingement regardless of closed or open kinetic chain activity.
There are three common types of impingement seen in the clinic, and PRI has implemented strategies to reduce the chance of these occurring.
Usually occurs on the right side when attempting to abduct. Described as a pinch below the iliac crest.
Needs to be able to abduct in left AF IR position.
There were so many other topics that were discussed here, but I wanted to provide some more in-depth discussion with some of my favorite topics covered. Get to a PRI course as soon as you can, as they continue to be the best in the biz.
“Madder than a wet hen.”
“You’ll learn one language in school and you’ll learn how to get patients better here.”
“What good does it do to strengthen a rotator cuff on a scapula that is not home?”
“If they can’t dance you’re going to have a hard time working with them.”
“A wink is as good as a nod to a blind mule.”
“Walking is a compensatory strategy.”
“Slicker than the center seed of a cucumber.”
“There’s no such thing as a left handed protocol.”
“Slicker than a peeled onion.”
“She’s grinning like a butcher’s dog.”
“Get a zone and 75% of patients get better.”
“Neuro always trumps orthopedic.”
“Everyone who wears flip flops is doing toe raises.”
“We should be smelling fried glute in a few minutes.”
“The spirometer doesn’t lie.”
“Screwed up as a soup sandwhich.”
“Slicker than a firehouse pole.”
“Only way you can get a reset is with a pause.”
“Why strengthen a rotator cuff on a skateboard?”
“If you just listen to country, you’re going to lateralize to the right.”
“I got no wrinkle in my britches and I’m fixin’ to shift.”
“Crooked as a goat path.”
“Hotter than a $2 pistol.”
“I don’t need to be at home depot all the time. Let’s do this.”
“Sweeter than sour with honey.”
“Nervous as a long tail cat in a room full of rocking chairs.”
“PTs write prescriptions to inhibit.”
“Quiet as a church mouse.”
“Once the toilet is flushed everything is gone.”
“Well don’t just do something, sit there.”
“Did you see that? I just metabolized.”
“Hawkins-Kennedy? Neers? I don’t know what that is.”
Several different thoughts have crept into to my mind sparked by what I have read and conversations I have had. I would like to share these insights with you.
I remember when I was visiting Bill Hartman Dad a few months ago and we were talking about a specific treatment that is quite controversial in therapy today. He said something that really resonated with me:
“Thus, pain can be viewed as a single perceptual component of the stress response whose prime adaptive purpose is to powerfully motivate the organism to alter behavior in order to aid recovery and survive.”
Notice what I bolded there. Pain is a single component of the stress response. Not the stress response. Not a necessary component of the stress response. Just one possibility.
Why do we place so much importance on pain?
Many proponents of modern pain science (myself included) often use this statement against individuals who are over-biomedically inclined:
“Nociception is neither necessary nor sufficient for a pain experience.”
Agreed, pain is not always the occurring output when nociception is present. That said, pain is only one of several outputs that may occur when a tissue is injured. Just because pain is absent does not mean other outputs are also absent.
Many different outputs can occur when an individual is under threat.
Let me propose a new quote to those who focus solely on pain.
“Pain is neither a necessary nor sufficient output of the stress response.”
Why should we limit ourselves to only treating pain? Why should we limit ourselves to only treating outputs? (Spoiler alert, we can’t treat outputs, change them) I have a better idea.
Today, I start treating a human system under threat.
The Threat Matrix
Dad showed me this great editorial here in which Eric Visser expands upon Melzack’s original pain neuromatrix.
Visser calls this idea the threat matrix. To simplify the idea, threatening inputs from the body and the environment enter the system, are scrutinized by the brain, and then the desired output to combat the threat occurs.
Input –> processing –> output
This framework explains how any output, desirable or undesirable, can occur from a stressful input.
Let’s apply this to an example that we have all been through; a breakup with a significant other.
Your significant other decides to leave you, how do you feel?
The answer depends on the individual. Some folks may feel depressed. Some may feel anger.
Some may even experience pain.
These feeling are all outputs that occur as a result from an input (i.e. the breakup) that disrupts homeostatic balance of the human system. The outputs that occur are the ones that the brain determines best aid the individual in recovery and survival.
Let’s now take this thought to the therapy realm. I sustain tissue damage and nociceptive information travels to the brain to be scrutinized. What output(s) could occur? Let’s think of a few possibilities.
Endocrine alterations in gut/reproductive function
Increased/decreased immune activity
Yada yada yada
All of these could occur, some of these could occur, or none of these could occur. The response to the offending input is going to depend on the individual’s brain scrutinizing the situation.
One could argue that a nociceptive event could lead to someone developing anxiety and poor immune function without ever experiencing pain if that is what the system feels best aids in survival.
Nonspecific Effects my Arse
There are many treatments out there that people deem worthless because research demonstrates minimal effects on pain compared to placebo. If someone gets better with this intervention, we deem that nonspecific effects led to the change in pain.
I call bullpoop…sort of.
Nonspecific effects could be a contributing factor to someone benefitting from a particular treatment, but the problem with most pain research is that often pain level is the only thing that is measured.
If pain is only one possible output of a system under threat, how do we know that a treatment didn’t affect a different output?
Answer: We don’t because it wasn’t measured!
Let’s take a controversial treatment for example: dry needling.
Some say it works wonders for pain, some are vehemently opposed, and research is mostly mixed. What do we do?
Perhaps both camps are wrong. Why? Pain is the only output being discussed.
What if this whole time, dry needling worked because it altered inputs coming in from the immune, autonomic, or [what the hell evahhhh] system, which led to changed output from this system primarily with pain output altered secondarily? And here is the kicker; the intervention only works if these systems respond as well as our pain system under a particular threat.
Well we don’t know that because we didn’t look at it. But looking at multiple systems when an intervention is implemented may give us more explanatory power as to why certain treatments help certain individuals. With this information, treatment could be streamlined and implemented.
Making pain our only concern to treat severely limit our capacity to help individuals. If we think of treating the stress response itself, we open up a huge realm of issues our interventions may affect.
If you take a look at the book “Spark” and the corresponding research, we see how exercise can alter many different outputs.
Why can’t rehab folks be a piece of this puzzle? It does not seem unreasonable to me that we could get referrals for anxiety, depression, or whatever output the stress response creates.
Strategically implemented exercise can help alter the stress response. That possibility makes me so hopeful for our professions.
How can one best assess a system under threat?
If clinicians are to assess if an individual is undergoing a chronic stress response, we need to find a reproducible methodology that gives us this information. We must look at the human system from the input/output standpoint.
There are several outputs that can be measured to assess an individual’s homeostatic state:
Other specific medical tests
These are all great tests that can assess the amount of system stress an individual is undertaking. That said, I feel there is an even simpler method of assessing the stress response:
Our physical examination
Assessing the stress response begins with the subjective examination. This piece of the clinician-patient interaction helps us assess potential offending inputs as well as individual processing.
If we come across red or yellow flags, we can easily refer out to providers who can deal with that piece of the stress response. Here is where a psychologist, surgeon, oncologist, other medical professional can come into play. These individuals can alter the offending inputs or help influence processing that therapists and the like may not be able to touch.
Let’s say we get through our subjective and we screen out that the above professionals do not need to be a part of this person’s care. Let us now proceed to our objective examination.
Assessing movement may be the simplest way to assess an individual’s stress status.
If we are to provide the “ideal” physical examination, we need to perform tests and measures that best differentiate a stressed from nonstressed individual.
To undertake this task, we need to have a few assumptions about what a nonstressed individual looks like. Let’s call this individual the “adaptable human.”
The adaptable human will have desirable multi-system variability. That is, human systems can perform as needed under certain situations without being “stuck” in a particular range. For example, blood pressure should stay lower when at rest and rise when performing physical activity. When blood pressure remains high at rest and with physical activity, that individual possesses system rigidity.
The adaptable human will have desirable multi-system capacity. That is, human systems can tolerate prolonged stressors without faltering. For example, a human can perform longer durations of physical activity with blood pressure remaining in levels that would not threaten one’s life.
The adaptable human will have desirable multi-system power. That is, human systems can tolerate intense stressors without faltering. For example, blood pressure can reach a desired level to allow for a particular physical activity to occur.
Our examinations ought to assess these three qualities: variability, capacity, and power.
Of the three, variability is most fundamental because almost every healthy human system functions in the manner. The movement system is no exception to this rule.
Movement variability, the ability to move in three planes, is the simplest reflection of this concept. A nonstressed system will possess movement variability. A stressed system shall become rigid and lose triplanar mobility.
Think to the last time you were stressed. Did your muscles tense or relax? As muscles tone increases, range of motion decreases. Assessing movement variability is an easy way to assess the general tone an individual has, and I speak more of why this notion is favorable here.
To assess variability, our examination must:
Look at the entire individual’s body
Cannot have bias toward one output (e.g. pain)
Must be reproducible and predictable
First, let’s look at popular rehab systems that I feel would not work in this instance and why.
Maitland: Biased toward altering one output (pain); segmental in nature.
McKenzie: Biased toward altering one output (pain); segmental in nature.
SFMA: Not necessarily biased toward one output, but does not look at entirety of human movement. Only two movement planes are assessed. Cannot see if an individual has variability in the frontal plane.
DNS: Wait? Do they even assess?
I shall let my bias now creep in as I suggest the current best model we have for movement variability is PRI.
There are several reasons why I think PRI is currently the best model to assess threat:
It is not biased toward altering one output, as movement rigidity can occur along with several other outputs besides pain.
The entire human movement system is assessed in three planes.
The protective patterns one undergoes in threat are predictable and similar for all individuals.
When one deviates from these patterns, likely pathology had to be created in order to do so.
If an individual can produce nonpathological triplanar movement throughout his or her body, then movement variability is present. A movement system under threat will not have this capacity. A threatened movement system will become rigid.
Establishing movement variability is our primary way to reduce threat-response outputs.
If undesirable outputs remain once movement variability is established, then we know other interventions must be given to address these areas.
If pain is still present, then previously mentioned assessment systems hold value, as does graded exposure.