Course Notes: PRI Integration for Baseball

Another Course in the Books

Back in November I had the pleasure of attending a new Baseball PRI affiliate course, taught by my homies Allen Gruver and James Anderson.

Ahh Cristal, my Moto, and a couple of PRI courses, why not?
Ahh Cristal, my Moto, and a couple of PRI courses, why not?

I really enjoyed this course because it was such a high-level affiliate and great prep for my PRC. We went into great deal regarding position, throwing mechanics, and treatment.


One of the most amazing pieces of the course was Allen’s ability to breakdown complex baseball movements into their basic biomechanical bits, And from that point show what compensatory things could occur if limitations are present. His eye for these things is unreal.

That piece of the course is a post or two on its own, so I won’t touch it here. In fact, I probably won’t touch it at all. Go to this great class and be wowed by Allen. You will be motivated to become a better clinician. I know I was.

Here are some of the big takeaways.

PRI 101 v 3.0

I’ve heard this overview three times this year now, and it is amazing that I still pick up things from it. James really outdid himself here.

The big piece this time around was space. We want space maximized.

Which is why I sit like this all the time.
Which is why I sit like this all the time.

In the vision course we discussed maximizing left peripheral visual space because the pattern reduces this quality. The pattern in general reduces our ability to move through triplanar space.

There are a few other reasons that we would be unable to shift into our left side. Overactive muscles chains may prevent this action, but we also have something very large occupying the left side.

We call this thing air.

If we are hyperinflated in particular areas (think left chest wall), how can we expect to go to the left side? Left space is already filled with air. Airflow must be transferred to the right side in order for us to maximally close down our left. Maximal left sided closure via a zone of apposition is necessary to create true left stance.


Patterns, Adductors, and Pecs (Oh My)

The right adductor magnus and left pec major, though not part of the LAIC/RBC pattern, are still very active muscles. Why is this so? These muscles prevent falling over when in right stance with left trunk rotation.

That PRI Doesn’t Work, I Got Someone Neutral and they Felt Worse

False! Here’s why.

An individual’s norm when under threat is the LAIC/RBC/RTMCC pattern. It’s autopilot; it’s what’s comfortable.

If frontal plane is Bob Ross, then LAIC/RBC is Ben & Jerry.
If frontal plane is Bob Ross, then LAIC/RBC is Ben & Jerry.

Let’s say you take that away from someone. They have greater movement freedom, but are not sure what to do with it or how to control it. This change could be perceived as a threat by the brain, and symptoms may increase as a means to prevent movement exploration into this new space.

I tell my patients when this happens it is like they just got their driver’s license and I gave them a Ferrari.

With some patients this is probably a bit more accurate.
With some patients this is probably a bit more accurate.

A Ferrari is a little more challenging to drive than most cars (so I hear, that blog paper hasn’t hit that level yet), so it’s going to be a bit harder to handle. Once the patient learns how to drive the Ferrari the possibilities are endless.

They must learn a new pattern (RAIC/LBC/LTMCC) in a nonthreatening manner so they obtain locus of control in this new position. Once integrity is achieved here, alternating reciprocal activity is ingrained to maximize movement variability.

Pattern Pitching Problems

Pitches ain’t shit

Depending on what arm you throw with, you are going to have a bit more trouble with certain aspects of pitching movements. I won’t go into the bazillion reasons why this happens like Allen did (go to the course yo), but here is what each throwing phase needs.


If I’m a right-handed pitcher, the LAIC/RBC is going to limit me. Let’s break it down to each throwing phase:

  • Wind-up – Need to turn on right posterior glute med to delay LAIC activity.
  • Stride – Need to inhibit right adductor and QL to maximize stride length.
  • Cocking – Need to shift into Left AF IR while maintaining right trunk rotation.
  • Acceleration – Need to keep Left AF IR in trunk flexion.
  • Follow through – Need to balance into left AF IR.


South Paws

If I’m a left-handed pitcher, the RBC, posterior mediastinum, and timing will be my largest limiting factors. Here is what I need at each component of throwing.

  • Wind-up – Need to load left AF IR and engage abs to stay back. Inability to do this is what creates that beautiful natural spin us lefties have when we throw.
  • Stride – Need to inhibit LAIC/RBC so one does not rotate too early into Right AF IR and right trunk rotation
  • Cocking – Need to control Right AF IR and left trunk rotation while reducing back extension and keeping adequate left posterior mediastinum activity.
  • Acceleration – Need to keep trunk closed down into flexion
  • Follow through – Need to balance into right AF IR.


Repetitive Rotation Superior T8 (Gasp)

This part was probably the most controversial and misunderstood piece of the course. The concept itself is not difficult to understand, but the material may seem challenging to fit into the PRI philosophy.

I’ve had several discussions with James Anderson on this topic to make the masses get the most up-to-date explanation for this pattern. Here is what we came up with [My post-conversation thoughts will be in brackets].

In the first two baseball courses, “repetitive rotation superior T4 syndrome” was used to describe a rare compensatory pattern seen in particular populations. James and Allen are now calling this pattern “repetitive rotation superior T8 syndrome.” The name changed because there are more ribs reversing the underlying LAIC/RBC pattern then the top 2-4 ribs. This change will be in all future baseball course manuals.

And now for the condition itself. There are certain instances, albeit rare, in which certain individuals may appear to have a reversed postural pattern (RAIC/LBC). Repetitive right trunk rotation occurs via various trauma and/or functional demands, such as the deceleration thru follow-through pitching phase for a lefty or the back swing for a right handed golfer, creating a thorax that is driven to the right.

You can also see this in PRI junkies who bias the left side only and never alternate [Like a right-sided hemineglect neurologically. If right-stance activities are not appreciated, variability may lowered possibly due to disuse. One possibility for this is also losing appropriate right zone of apposition while in left AF IR, to which I will discuss in a future post].

This T8 syndrome differs from classic superior T4 because more drivers push the thorax to the right and externally rotate the right ribs. In the T4 case, the scalenes elevate the upper 2-4 ribs to meet excessive respiratory demands. In T8’s case, the left BC kicks into high gear and drives more of a PEC/bilateral AIC pattern. It may mimic a RAIC/LBC, but not be the case.

With the thorax rotating hard to the right, the pelvis and lumbar spine must orient left and into a pseudo-left AF IR translatory-type movement. Consequently, these folks stand and function quite well on their left leg compared to the right.

Seeing a “flipped” pattern is nothing to freak out about; there are still underlying LAIC/RBC patterning at play. This repetitive rotation superior T8 syndrome is an atypical compensatory strategy that requires atypical treatment.

Interventions basically flip normal PRI activities; shifting into right stance with left trunk rotation. We technically cannot call this “PRI” because the underlying human asymmetry is not addressed.

Treating in this fashion does however put the system into a “normal” asymmetrical pattern to which conventional PRI methods can be used. [That said, the name of the game has always been alternating and reciprocal activity. Everyone should be able to do traditional PRI activities on both sides without falling apart. The reason why this is not called PRI is because of the order treatment occurs in].

[The big message at the end of the day: Trust your measurements and treat accordingly].

Elbow and Wrist Drive Thorax

This portion was one of my favorite pieces of the course; namely because it’s not talked about anywhere else in PRI land.

There are 4 possible patterns on the left and right side that can occur at the humeral-radial joint; depending on the position of each.

I won’t go into details on each, but basically if you see increased mobility in one direction (supination or pronation), you likely want to inhibit that direction and facilitate the converse.

Wrist flexion, pronation, and internal rotation facilitate serratus anterior and contralateral thoracic rotation.

Wrist extension, supination, and external rotation facilitate lower trapezius and ipsilateral trunk rotation.

 Reference centers in the wrist and hand can also be used to facilitate position. When attempting to facilitate left stance with right trunk rotation, use a right pisiform and left palmar arch.

Dat’s It

So there you have it. Some of my favorite pieces from this excellent affiliate courses. It’s filled with a ton of information, and is easily the most challenging conceptually of the three affiliate courses I have taken. You won’t regret this one.

Unlike that one course...Or three (sigh)
Unlike that one course…Or three (sigh)

Great James Quotes

  • “If you see a forward head, hand them a card that says exhale please.”
  • “Inhaling in a state of exhalation is neurologically cool.”
  • “It’s not magic. It’s better than magic. It’s neurologic.”
  • “We’re gonna talk about trauma called throwing a baseball 95mph with your left hand.”
  • “That muscle firing is a total waste of sarcomere slide.”
  • “Your brain is a better parent of your body than I was my son.”
  • “Ron is looking at the brain, not the plumb line.”
  • “A plumb bob and grid is offensive to Ron Hruska.”
  • “What have you thought about the fact of never blowing up a balloon as a grown man?”
  • “He sucked a lot of balloons empty.”
  • “Hand on the heart for serratus anterior. Go ahead.”

 Gruv-y Allen Sayings

  • “You are only as good as your patient will allow you to be.”
  • “I can’t stand research to a point.”
  • “It depends.”
  • “The right QL and adductor are best friends…Just like James and I.”
  • “Don’t judge someone just by video.”
  • “You can’t make a program based on a screen.”
  • “If you’re not doing test-retest give them they’re copay back. You are failing them.”
  • “One pound dumbbells are not changing my patient’s lives.”
  • “We’re facilitating neurology.”

Course Notes: PRI Vision Integration for the Baseball Player

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.

Being mindful of your surroundings was key to the course.
Being mindful of your surroundings was key to the course.

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.


I at least had one half of the equation most of my childhood.
I at least had one half of the equation most of my childhood.

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!

No Sam, it's not.
No Sam, it’s not.

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.

Those eyes. They...They see really well
Those eyes. They…They see really well

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.

I didn't see the light 'til I was already a man...Could've been why I am  a vision patient.
I didn’t see the light ’til I was already a man…Could’ve been why I am a vision patient.

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.

It's a big deal.
It’s a big deal.

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.

Worse than Battlefield Earth, or for that matter Travolta's career after that movie. Blek.
Worse than Battlefield Earth, or for that matter Travolta’s career after that movie. Blek.

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:

  1. Visual focus (inhale)/Visual relaxation (exhale)
  2. Central vision awareness (inhale)/peripheral vision awareness (exhale)
  3. 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.

Shame on me.
Shame on me.

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:

  1. Focus on an object that is 5 feet away or closer.
  2. Find an object that is at least 15 feet away.
  3. 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.

Boom. This makes the third Batman reference in one post. A new record.
Boom. This makes the third Batman reference in one post. A new record.

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.

#highperformance #message
#highperformance #message

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.

It's tearin' me apart!
It’s tearin’ me apart!

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.

Dude...Didn't really get this movie but whatever.
Dude…Didn’t really get this movie but whatever.

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. 

Everything. Trust me.
Everything. Trust me.

Think of all the reference centers a baseball player could have that could keep him extended:

  • Outfit
  • Baseball cap
  • Glove
  • Cleats
  • Chew/gum/sunflower seeds
  • Anything
RIght TMCC brand I believe
RIght TMCC brand I believe

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.”
  • “Eyes are the brain’s way of touching the world.”

Course Notes: PRI Impingement and Instability – Cantrell Edition

A Quick Trip Home

 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.

Will be said every time I go back to Illinois
Will be said every time I go back to Illinois

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.

Learn on.

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.

Do you think it would bother Charlie if I quote him in a PRI blog???
Do you think it would bother Charlie if I quote him in a PRI blog???

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.

Stability leads to extension, extension leads to impingement, impingement, leads to suffering.
Stability leads to extension, extension leads to impingement, impingement, leads to suffering.

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.

Compensatory Strategies

 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.

Newest PRI orthotic for my favorite compensatory strategy. Unfortunately only 10% of you will understand...
Newest PRI orthotic for my favorite compensatory strategy. Unfortunately only 10% of you will understand…

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.

Comes prelateralized. Buy yours today.
Comes prelateralized. Buy yours today.

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?

Like oh I don't know...Maybe this guy?
Like oh I don’t know…Maybe this guy?

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.

Anterosuperior acetabular femoral impingement (ASAF)

  • Usually occurs on the left when attempting to shift into AF IR.
  • Demonstrates need for anterior glute med, so bias FA IR before shifting into AF IR.

Anteromedial femoral acetabular impingement (AMFA)

  • Usually occurs on the right when attempting to IR the femur or with posterior translation of the humeral head in flexion.
  • Reflects need of a right glute max.

Laterosuperior femoral acetabular impingement (LSFA)

  • 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.

That’s It

 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.

Good times had by all.
Good times had by all.


  • “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.”
  • “Naw hell.”
  • “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.”
The only time I've seen Mike nervous.
The only time I’ve seen Mike nervous.

Course Notes: PRI Integration for Yoga

Portland is Cool

The PRI road show continued on to Portland. This time I learned how PRI integrates with Yoga from the masters—Emily Soiney and James Anderson.

In our cute yoga outfits.
In our cute yoga outfits.

Coming into the course I was incredibly biased against Yoga. I’m not a huge fan of crazy mobility expression, which in PRI-land could potentially lead to pathology.

Moreover, the crowd that is typically attracted to yoga is of the more flexible variety. Bad news bears.

That being said, Emily pleasantly surprised me.

This is why you don't give me pictures from the course.
This is why you don’t give me pictures from the course.

With the way Emily teaches Yoga, I see it more now as an expression of moving within your limits; not going beyond those limits like many poses attempt to do.

Yoga can be done right, and when it is it’s fahkin’ haad!

The goal for PRI-inspired Yoga is to keep the zone of apposition (ZOA) while expressing how far you can move. If you lose the ZOA, then movement integrity is diminished.

Let’s find out how we can do that.

Yoga Overview…Yogarview???? Whatever

 I came into this course knowing piddly diddly about yoga. Which being around several yoga practitioners was a big mistake.

un 1
Not as serious as Emily’s, I fear.

There was a lot of Yoga terminology and posing that was discussed nonchalantly, which more than a few times had me lost.

I now know how those who are not familiar with PRI feel taking a course for the first time.

I only blame myself though. Make sure you are prepped when you go and at least have basic familiarity with basic yoga poses, verbiage, and tenets.

There is much more to yoga than just poses and breathing. In fact, there are 8 limbs of yoga, broken up into two categories

Category 1 – Things you do

  • Yamas – Restraints from harming, lying, stealing, hoarding, etc
  • Niyamas – observing cleanliness, content, zeal for yoga, self-study, and surrender
  • Asana – The posing
  • Pranayama – The breath
  • Pratyahara – Withdrawal of the senses
  • Dharana – Intense focus

Two strikes for me so far.

Category 2 – Things that happen to you

  • Dhyana – Meditative state
  • Samadhi – State of oneness


The methodology aims to bring harmony among one’s physical, mental, and spiritual self.

Yoga, much like PRI, aims for integration through position, airflow, and autonomics.

Yeah, she can levitate words. It's pretty creepy.
Yeah, she can levitate words. It’s pretty creepy.

The PRI-side for da Haterz…This is What PRI is Not

 As with all affiliate courses, the PRI overview is given. I went into detail on this here, but with the same material I still picked up some good points.

A lot of da haterz on da interwebz give PRI flack because posture (gasp) is in the name.

However, PRI is not discussing posture in the traditional sense.

In fact, James feels that PRI does the opposite of normal posture training.

Traditional extension-driven posture training disrespects the nervous system, tones and tightens areas, and looks good.

Don't always listen to your parents.
Don’t always listen to your parents. Slouch for once.

To contrast, PRI respects the nervous system, relaxes, and feels good.

The way PRI achieves this respect is by starting with a more flexed posture. This position alleviates deformation along the sympathetic ganglia and elongates the nervous system. This positioning aids in creating a state of neurological rest.

From this position, extension and uprightness is added to the program while attempting to maintain some semblance of rest.

One big PRI goal is to achieve neutrality. This autonomic and arthrokinematic transition zone is what allows access for end-range at either spectrum.

We move from flexion to extension, abduction to adduction, external rotation to internal rotation, sympathetic to parasympathetic. With all of these end-ranges potentially occurring simultaneously in a human system. This ever-changing flux creates disorder, options, chaos, variability; qualities in which the human system thrives.

Neutrality simply unlocks that capacity.

The Pause

 The pause is an essential piece in how PRI teaches breathing, but why?

I'll tell you why
I’ll tell you why you’d…want…it…that…way.

After the full exhalation, the diaphragm is maximally domed and the zone of apposition (ZOA) is at its greatest. In other words, the diaphragm is in a relaxed state. When the pause occurs post-exhale, the diaphragm spends time out of tonicity, and the human system spends time in a parasympathetic-dominant state.

During both this pause and inhalation, the tongue ought to be pushed up into the palate. This movement helps balance the stylohoid and 16 muscles that attach to the sphenoid. Keeping the tongue here is the best way to shut off the neck without orthotics.

A PRI Brain in a Yoga World

 Once we got a PRI and Yoga overview, it was time for Emily to take over.

First order of business was screening individuals. The screen utilized consisted of active tests to help the practitioner determine what protective pattern a client is in. The only missing piece that I saw here was lack of a frontal plane test, which would further enhance the screen’s strength.

There were also active functional tests that give insight as to what pattern-opposition muscles a client can use to decrease this protective tone. The nice thing about these tests in particular is that they are already yoga poses; more attention is just paid on what areas the client perceives as working.

From here, poses were demonstrated with the planes in mind, and suggestions were made about what poses (asanas) would be beneficial/harmful for most individuals:

How Asanas hurt

  • Repetitive movements with lack of variety.
  • Disrespecting spinal curves and girdle biomechanics.
  • Transitions that could potentially create impingement.
  • Emphasizing the pose’s end result or aesthetics instead of subtleties.
  • Dyssynchrony between alignment and breathing cues.
  • Not allowing clients to rest.
  • Overemphasizing an inherent planar imbalance in a body region.

How Asanas help

  • With intelligent sequencing.
  • Enhancing body and breathing awareness
  • Implementing movement variety.
  • Correctly mobilize tissues.
  • Respect joint mechanics.

To summate, Yoga can be done right or wrong. The best way to keep yoga safe is by keeping the ZOA as best as possible.

Yoga Considerations

In talking purely sagittal plane, mass flexion ought to occur in the forward bend. One starts with combining thoracic flexion with a posterior pelvic tilt. The hip should be in a state of flexion, abduction, and external rotation.

It is critical in backward bends that the ZOA is maintained. Hip positioning ought to include hip extension, adduction, and internal rotation

Reference Centers/PRIYAS

 A reference center is how we integrate with the world. They were called PRI Yoga Awareness Sites (PRIYAS) in this course. Finding and feeling these areas is key to integrating left-sidedness into our environments.

If you or your client cannot perceive these areas well, right lateralization likely knows who you are.

The PRIYAS include:

  • Left heel – Connects ankle dorsiflexion with hip extension.
  • Left sit bone – Likely has a neutral pelvic outlet and can shift into the left hip.
  • Left abdominals, hamstrings, adductors, and gluteus medius – Has ZOA, neutral pelvis, and can shift into the left side.
  • Right gluteus maximus, rectus femoris, lower trap, and triceps – Can likely maintain neutrality while on the right leg.
  • Right arch – Mirrors the right hemidiaphragm; keeps foot neutral in frontal plane.
  • Left posterior mediastinum – Shows airflow into an inhibited area; accessory muscle breathing is reduced. Predominately sagittal.
  • Right lateral posterior superior ribs – Signifies frontal and transverse plane airflow.

 Cauuuute Cauuuuuues

Emily is a cueing monster. ‘Nuff said.

The little nuances that she used in many of the activities are worth the price of admission alone.

She had a nice way to cue spinal elongation. Where should you elongate? Through your bregma bro!

Another good way to cue head position is to pretend there is a grapefruit underneath your chin. I really like this cue because it insures that excessive cervical retraction does not occur. We don’t want much cervical retraction because that would promote cranial extension, thus contributing to extensor tone.

In some of the PRI manual techniques, we place our hands on the sternum to facilitate a ZOA. The same thing can be done with your thumbs. It is quite amazing how providing this reference for your sternum can influence diaphragm position. It personally demolishes my lower traps.

Emily also had a great cue during reaching to better engage serratus. Many folks have a tendency to elevate their scapulae when they perform a reach. However, if you lead the reach more with your pinkies this tendency seems to melt away.

 I thoroughly loved the language she used for the PRIYAS as well. Here were my favorites

  • Left heel – Grounded, rooted.
  • Left sit bone – anchor, draw the hamstring pulley down.
  • Left abs/adds/hams/glute med – Kid hugging your waist; pull your leg out of mud.
  • Right gluteus maximus, rectus femoris, lower trap, and triceps – pull the lawnmower
  • Right arch – spread your foot
  • Left posterior mediastinum and right lateral posterior superior ribs – Breeze blowing in an open window
Whatever it takes to get a ZOA I suppose
Whatever it takes to get a glute med.

Zac’s Favorite Moves

 Playing with your nose is an excellent preparatory technique for yoga.

Emily showed us an alternate nostril breathing technique, which parallels the infraclavicular pump. The left nostril has more parasympathetic and right cortical connections, whereas the right nostril is more sympathetic and left. We want to maximize both of these qualities.

Some other neat activities that I could see myself using clinically were the Pose Dedicated to the Sage Bharadvaja

I was finally able to bring my butt down to the ground with that one.

I also really enjoyed the bent knee moonrise, which is a great way to simulate left stance.

I have also been using the side angle pose quite a bit. I’ve found it do wonders for intercostal inhibition as well as simulating left stance

The Verdict

 Overall, Emily put together a solid course, and definitely convinced me that yoga can be done safely. It is now just a matter of education those yogis and yogettes on how to perform these tasks in a favorable manner.

Yoga may not always break you.
Yoga may not always break you.

 Emily Quotes

  • “A $500 course on how to calm down? I’m just gonna sit here and breathe. “
  • “Yoga is what I’m feeling.”
  • “Feeling the heel can be very spiritual.”
  • “I missed what you said because I was laughing at my joke.”
  • “You just got the huge T-bone. Grassfed.”
  • “I was joking because my pelvic floor came on. I’m glad you didn’t see that.”
  • “I feel like I have to do a séance when someone can’t feel a muscle.”
  • “I so ZOA’d.”
  • “I’m so glad you’re here.”
  • “Can you shut your neck off? No? Get out of that class.”
  • “[A patient] I have a tendency to arch the back. [Emily] I know sweetie.”
  • “I just feel so sorry for this right hip.”
  • “Yoga practice is about taking care of yourselves.”
  • “Transverse plane is icing on the cake.”
  • “Why say something if you don’t know what you’re talking about?”
  • “You cannot direct air into your lungs. I’m sorry.”
  • “You don’t want to stretch or strengthen someone in a torqued, lateralized system.”
  • “I’m super spoiled…Not really I worked hard.”
  • “You have a PRI nation behind you. We will take them on!”

 Great James Quotes

  • “It’s so not a plumb bob.”
  • “You need to breathe all the way out or don’t play the game.”
  • “I’m so sick of talking to physical therapists I could puke.”
  • “Getting it [air] out is the show.”
  • “Why is his head forward? Did he just decide today was forward head day?”
  • “You can’t be flexed in a state of inhalation.”
  • [On walking early] “Yay! Look at baby! Gonna have fibromyalgia!”
  • “Why are you growing your tummy when your lungs aren’t in your tummy?”
  • “You went from jacked to super jacked.”
  • “You can’t flight the brain.”
  • “It’s not my little pattern.”
  • “You know how many stretches in PT school they taught me that I wish I never known?”
  • “Asia likes neutrality and flexion. We like extension and surgery.”
  • “There’s a new sheriff in town called reality.”
  • “The brain is the show. Tweet that!”
  • “PRI is not on trial. You know what’s on trial? Crap that doesn’t work.”
  • “Ever do crunches with a neck strain? What a great way to integrate headache…things.”
  • “Would you call them yogi’s and yogettes?”
  • “You look neutral baby.”
  • [On manual therapy] “Brain is better than a hammer.”
  • “If you’re talking triplanar, I’m going to give you a high five and take this little star and put it near your purple hair.”
  • “You wish you had a slippery right bra.”
  • “Exhalation is a triplanar move.”
  • “Other than the brain, Grand Central Station, the diaphragm is at the heart of human performance.”
You say you walked early??


A Fly on the Wall of the Hruska Clinic

The Saga Continues

 This post is way over due, but a lot has been going on in life.

I have just moved to Arizona to start anew, and the change is bittersweet.

The Midwest is all that I have known for the past 27 years. I’m leaving a lot of loved ones behind that I will miss dearly.

However, getting out of the Midwest to a warmer place has always been a dream for me, and I finally got that opportunity. I also get to work at an awesome clinic alongside like-minded clinicians. One of my good friends will even be there.

This is how I envision day one of Young Matt and I in the same clinic.
This is how I envision day one of Young Matt and I in the same clinic.

Plus, summer forevaaaaaaaaaaaahhhhh!!!!!!

So with this transition in my life marks a good time to reflect on one of my many experiences at the Hruska Clinic. This time, I will show you how the clinic itself operates.

And their operation is a beautiful thing.

I was at a clinic once, and it was beautiful, like you.
I was at a clinic once, and it was beautiful, like you.

The General Feel

You walk in the door and can immediately shift into your left hip.

That’s what this place is like upon entering. With various shades of purple and tan, you just feel at ease being there.

It screams parasympathetic.

This build was no accident of course. Purple is a calming color, giving those at the clinic a huge home-field advantage. I bet there is also a reason why you walk left to check-in at the front desk.

Perhaps Beyonce knows more than she lets on...
Perhaps Beyonce knows more than she lets on…

The clinic is an interdisciplinary dream. The staff includes 5 physical therapists, an optometrist, a dentist, and a podiatrist. This setup allows for great communication among disciplines in order to provide the best individualized care for the patient at hand.

It was no big deal to call over the dentist to walk in and check out a patient during a session.

The physical therapists are where most people’s care starts. What is nice is they have several resources present to determine when to triage a patient to another provider. The clinicians had PRI glasses, orthotics, Asics shoes, mouth guards, and arch supports readily at their disposal.

Not everyone gets sent to another provider day 1 of course. Patients spend a few sessions working with one clinician, and if progress stalls then other options are undertaken.

The Session

A typical session at the clinic lasts 1 hour, and is all one-on-one care. Initial evaluations are very personalized to the patient, and much time is spent getting to know that individual. Not just from a physical therapy standpoint, but on a personal level. It was quite refreshing.

Almost as refreshing.
Almost as refreshing.

Objective examination consisted predominately of PRI testing, followed by large amount of education on pattern and position.

 Most of the clinicians utilized various analogies to describe how PRI is performed. I heard various things ranging from car alignment, to wings on a plane, but what was emphasized with all these alignment-based analogies was that this position is normal. It is our position of comfort.

They also use the tests, and how quickly tests change, as educational pieces. The clinicians also liked showing natural asymmetries, such as the preference in which one crosses his or her arms, or the way one stands.

I personally would’ve like to see more pain neuroscience-based education, as you could see some patients start to get a little concerned regarding what was being told. The patient’s still got better of course, but anything to reduce threat perception is critical.

I can’t count how many times I’ve seen hip internal rotation measurements improve after a successful therapeutic neuroscience education session. Perhaps a PRI pain science affiliate course is in due order? 🙂


It's a possibility.
It’s a possibility.

After education, the exercise program was implemented. Few exercises are given, but they are worked on for a large period of time. Form is to be impeccable by the end of the session. This work is needed since most patients are seen only once every one to two weeks. I love this frequency because the locus of control falls directly on the patient.

Helpful Tidbits

That’s pretty much the general clinic flow, and in my opinion it is the ideal treatment setup for patient success. The interdisciplinary care alone creates large variability in types of patients seen. Diagnoses I saw included pectus excavatum, “brain fog”, POTS, and chronic pain of all sorts. To me, that is the power of targeting the autonomic nervous system. You can affect any “diagnosis” that has an autonomic component; something PRI has a leg up on compared to most.

The remainder of this post is just going to include some various tips I picked up while there. The Hruska Clinic is definitely a neat place to see and worth the price of admission to observe (it cost $250/day to hang out).

 I Have a Vision

 You might be a vision patient if…

  • Have to reread pieces frequently.
  • You track with your finger (finger becomes a reference center to help your eyes track).
  • You have blurred vision.
If only Jeff Foxworthy grew up in Nebraska.
If only Jeff Foxworthy grew up in Nebraska.

I also got to observe a patient in PRI vision. It was a cool experience especially after going through it myself.

The patient had a 3-level cervical spine fusion with chronic neck and lower back pain. It was clear that the pain system was  centrally sensitized, but what about the visual system?

As the patient walked, you could see minimal trunk rotation, large amounts of valgus collapse and pronation. Heidi, the resident optometrist, altered the patient’s lenses by 0.25 diopters. With that small change alone, the patient began walking with pelvic and trunk rotation, as well as decreased knee and foot collapse. She also reported less pain. So as we can see, the pain system is not the only system that becomes sensitized in chronic pain. Multiple systems, dare I say the individual, becomes sensitized.

“That’s a sensitive system.” ~Ron Hruska

It is possible that pain could increase with glasses on if tone is brought down low enough. The stability created by tone is taken away and control of new neurological space is not present. This is a threat to the system, which could lead to a pain experience in order to protect the patient.

Other tips:

  • PRI Vision Lite – Put reading glasses on someone and see if they let go. I personally have done this for several patients and it has worked wonders. I Had a woman who had shoulder pain, and I tried just about everything I could think of to alleviate her symptoms. No change. She puts on a pair of +1.0 reading glasses = no shoulder pain.


At a PT clinic near you.
At a PT clinic near you.

All Bite, no Bark

I generally have a hard time explaining how the stomatognathic system can play a role with various complaints, but one piece stood out to me quite well:

“If you have a piece of hair in your mouth, you can immediately feel it.”

This instance shows just how sensitive teeth can be. The stomatognathic system is neurologically-rich area for sensory input, and the trigeminal nerve has links to multiple body areas.

Other neat things I picked up:

  • Test patients by having them line up their three fingers in their mouth to rule out bite as a driver of position. This position allows the discs to rest.
  • On pulling teeth: If you are missing teeth you are missing a reference. So don’t pull if needed or neutral. Try to create room first. If that is not possible, then teeth must be pulled.
Aka my wisdom teeth. Jerks.
Aka my wisdom teeth. Jerks.

Testing Tips and Tricks

  • Watch how a shirt wrinkles when someone walks to see if trunk rotation is occurring.
  • If someone is sitting in bilateral hip internal rotation, the psoas is likely kicking in as an external rotator and pulling the spine forward.
  • During the Hruska adduction lift test, areas need to be felt. If you can’t feel something, then you need to inhibit something. Should feel at least 5/10 activity rating.

Nonmanual Tips and Tricks

  • For Exhaling – Think about the sigh you make when your mom and dad tell you to clean your room.
  • If someone gets excessive cramping with an activity, you need to inhibit something.
  • When performing a step up and over, reach forward with the right leg.
  • If the patient is having a hard time feeling the left IC adductor, go after the right intercostal.
  • If TFL or glute med kick in during an activity and the IC adductor is not felt, perform pure adduction activities with the knee and hip extended.


Likely neutral through most of my childhood.
Due to frequent exhalation, I was likely neutral through most of my childhood.

Manual Tips and Tricks

  • [Comparing manual to nonmanual techniques] – Left arm reach is equivalent to a left pec mobilization; right arm reach is equivalent to a subclavius release.
  • A good manual technique – Use your hands to create OA extension by providing a patient with a cervical lordosis. This is how I feel traction ought to be truly done. As when you perform traction (anyone still do that?), cervical lordosis is reduced.

Clinic Quotes

  • “We don’t have proof, just a theory.”
  • “As your bite changes your vision is going to change.”
  • “Every time I touch my teeth I twist.”
  • “A balloon is theratube for your abs.”
  • “We don’t know.”
  • “If you’re not sleeping you’re not living.”
  • “All clenchers and grinders have no reference. Period. End of discussion.”
  • “I’m so sorry to make you do that.”
  • “The pattern doesn’t cause pain, but is an influence.”
Unless...ya know.
Unless…ya know.

Treatment at the Hruska Clinic: The Finishing Touches

For part 1, click here.

For part 2, click here.

A Low Key Day 3

 Day three consisted mostly of putting the finishing touches on my quest toward neutrality.

The morning began by tweaking my gelb splint so I was getting even contact on both sides. This way I would be ensured to not have an asymmetrical bite.

I put a pair of trial lenses that fit my PRI prescription, and grinding commenced. We finished with this:


Complete with official saliva
Complete with official saliva

Once the splint was done, I had a final meeting with Ron to go over my exercise program.

I was placed into phase one visual training with two pairs of glasses. My training glasses were to be used when I lift weights, perform my exercises, walk around, etc. I could wear these for up to 30 minutes at a time; making sure I maximize my visual awareness of the environment.

While I was wearing these glasses, I was to be keen on finding and feeling my heels; especially when I turn my head. The glasses would help me find the floor, as well as help my eyes work together and independently from my neck.

My second pair of glasses was to be used while performing any activities within arms reach. This pair helps my eyes converge better and promote less eye fatigue.

Ron gave me several phase I vision activities as well as a few others. His main objectives were to get my eyes to move independent of my neck. We also wanted to create thoracic rotation on my rock-solid hip alternating capacity.

Here was my list:

The first activity helped with differentiating eye and neck movements.

The next activity was more alternating reaching in left stance; key is to keep eyes on left arm.

This beast below used a mirror to help me visualize doing the exact opposite pattern that I was trying to create; more visual tricks.

This next exercise utilized viewing the environment while using my alternating skillz

And here we have another very good alternating thoracic activity.

The Neutral Lifestyle

 I’ve had my splint for a month, reading glasses for 3 weeks, and consistently using the training glasses for 2 weeks now.

In just that short amount of time I’ve noticed quite a few changes. Granted, there could be many influences as to why these things have occurred, but I’ve tried to minimize as few variables as possible.

I've tried so hard even.
I’ve tried so hard even.


This area is where I’ve noticed the most changes. My recent program block for the past couple months or so has been very aerobic based. I lift weight 3 times per week at mostly tempo style. The other 2-3 days I train consists of one day playing basketball for cardiac output and either high intensity continuous training on my bike and/or tempo intervals with a jump rope or sled.

Before glasses (BG), I was measuring my heart rate variability (HRV) and resting heart rate (RHR). These numbers have not budged much with the month or two that I have been training like this. But after glasses (AG), I have noticed general trends of my HRV being higher and my RHR lower.

Exhibit A
Exhibit A. Slacked on measuring for a while, but was not budging from 3-4/2014

The HRV changes are what impressed me the most, as I have had many more outside stressors occurring in this time period. So despite being in a higher stress environment, my HRV climbs.

In the weight room itself, the load I have been lifting has generally tanked. I have lost strength in many of the lifts that I was doing, yet I’m actually feeling more work occurring in the areas that ought to be working. My neck and back seem to be kicking in much less. This was a pleasant surprise. I also seem to get less tired during the aerobic stuff I have been doing. Again, these changes could be due to time, but most of these reports have not changed in the few months that my aerobic training has occured.

The craziest change yet? Without performing any true “jump training,” I was able to easily grab the rim on a 10-foot basketball hoop for the first time since high school.

The Arizona POTS population shudders, my fiancee just shakes her head.
The Arizona POTS population trembles.

I can also now perform a full deep squat unsupported, which is something I have been practicing since January. I was unable to do this until the second week AG.

Regular Life Stuff

 Many more changes have occurred to me with just regular life stuff. I generally feel much more rested after sleeping, even if I get less hours than I am normally accustomed to. I also don’t seem to get as many afternoon lulls as I used to.

Reading. Oh My lanta. What a huge difference. I am retaining quite a bit more of what I read, and find that I do not get eye fatigue. Like, at all. Even if I am on the computer for a very long time.

Neck tension has been variable. I notice quite a bit less when I am reading, but I still tend to feel it if I am away from my orthotics, driving, or extremely stressed. The frequency this tension is present is quite a bit less.

I do still get some jaw clicking with opening, but the gelb splint seems to decrease this frequency quite a bit.

Overall, I generally just feel good.

I knew that I would.
I knew that I would.

Why Neutral

 I have had a lot of people ask me why I went through this process, especially if I do not have pain. Curiosity and need for completion drove me there, but I left with so much more than I thought I would ever get.

The nervous system craves three things: movement, space, and bloodflow. As a PEC with limited mobility in every plane, my system was not getting space. Less space increases stress to my nervous system, which may or may not have led to many possible outputs.

Pain is only one of many outputs that a system under threat could produce. Perhaps an output could be hypertension, dizziness, fatigue, heartburn, decreased attention, inability to learn, constipation, anxiety, depression, etc.

Maybe even a decreased vertical jump could be an output in response to system threat.

Likely anything that has a large contributing factor from our normal stress response could be affected favorably by decreasing system load through achieving neutrality.

Possibly affecting everything this guy has written.
Possibly affecting everything this guy has written.

It is here that I feel PRI is leagues beyond any other treatment methodology, and could potentially have impacts beyond pain; something many conventional PT methods may not always address. It is not because these methods are bad or do not work, but it is because they are only addressing a few pieces of the human system.

PRI is the only framework I have seen that addresses and explains most completely how the human being functions under threat.

Does that mean PRI is going to cure everyone’s problems? Probably not. Some conditions could be too far gone, some may have causes/effects beyond our normal stress response.

You cannot know if something will be helped or harmed by PRI until you take the autonomic nervous system out of the equation. And that is how I believe PRI works.



Treatment at the Hruska Clinic: PRI Dentistry and Vision

For part 1, click here

For part 3, click here

Jaws will Drop

 I’m in the dentist chair, The room slowly get darker and darker. I feel my mouth open, and I wasn’t sure what would happen next.

Then Dr. Schnell places the necessary goup in my mouth to get an impression for my splint. I bite, and out comes the finish product.

You live to see another day. Bastards!
You live to see another day. Bastards!

Before the impression was taken, Ron came in and explained what he was hoping to accomplish. He wanted to fit me for a gelb splint to give my tongue some space to move in my crowded mouth. This splint would also help bring my mandible forward.

Dr. Schnell: “Is he neutral right now?”

Ron: [throws a towel over my eyes and sets my neck in a lordosis] “Now he is.”

And with that, the above sequence occurred and I was ready for vision.

Don't forget to bring a towel when you do your PRI exercises.
Don’t forget to bring a towel when you do your PRI exercises.

I couldn’t leave the room without that overarching reminder Ron gave me:

Ron: “Margo, if this was your son, what would you do with those wisdom teeth?”

Dr. Schnell: “I’d have them pulled.”


An Eye Opening Experience

 It was so much fun watching Ron and Heidi teach together, that I could only imagine what it was like seeing them treat.

They did not disappoint.

My session was getting videotaped for their marketing department, so I again told them my story. It ought to end up on the Internet sometime, so stay tuned for that!

They began the session by showing some of my mobility limitations:

  • HG IR: 20-30 degrees bilaterally, if that
  • HG horizontal abduction: 15 degrees bilaterally.
  • SLR: 30-40 degrees bilaterally.
  • Adduction drop/obers: + bilaterally.
  • Passive hip abduction: 30ish degrees bilaterally.
  • Cervical axial rotation: 10 degrees left.
  • Cervical sidebending: limited right.
Only known extension I have.
Only known extension I have.

The intervention consisted of me trying different lenses, walking, and retesting.

Each lens gave the environment and me a completely different feel. Some lenses made me shift most of my bodyweight to the left, some would make me feel shorter, and some would tighten my neck or my back.

Almost every time they gave me a different lens my tests would change. HG IR would go to 70 degrees one time, then 90, then back to 70. Straight leg raise steadily increased until it got to 90; crazy changes just with glasses.

Ron: “See that’s not fair, she [Heidi] knows more than me.”

The big tests for them, regarding when they knew they “had me,” were the standing global-orbital rotation (SGOR) and standing cranial tilt test (SCT). The former looks at transverse plane activity, and the latter frontal.

The SGOR came fairly quickly from what I remember. Many lenses had a hard time getting me to my left heel, but eventually the right pick was found.

The SCT was a little different beast. I was fairly solid from the waist down, but once neck movements were into play I had a much harder time maintaining my balance; at least without the glasses on. Once they found me the right pair, I was golden. Fully neutral and near-master of the frontal and transverse plane.

Time to get mobile.
Time to get mobile.

The Hardest Vision Test Yet

 Heidi and Ron were pleased with the choices made for my training glasses, but Heidi’s largest worry was having me maintain neutrality while I read. A bulk of my day consists of documenting at the computer, writing, and reading books/journal articles. She knew that I needed to be rock-solid there.

I had my first vision exam a month or so before I trekked to Lincoln, and my results were “unremarkable” to my optometrist. I am slightly hyperopic in my right eye (+0.50 for you optometry nerds) and myopic (-0.25) with a slight astigmatism in my left eye. My clarity is 20/20, so I can see fine, but Heidi felt that I had some marked left eye dominance. The above measures are a normal in the PRI pattern.

This dominance was very evident with my reading. Heidi had me sit and read a magazine while she watched me scan the print. She noted that my eyes do not work well together. I knew this very much so, as I always felt a difficult time converging on a very close object.

Funny, my eyes and tongue do the same thing at close objects
Funny, my eyes and tongue do the same thing at close objects

We would try various lenses while she asked me what it was like reading. The strangest thing happened once she put +0.50 in my right eye and +0.62 in my left eye.

I was retaining what I was reading.

That is the best way I can explain what I felt. I oftentimes had to read passages multiple times to comprehend, and thought nothing of it. I thought this was “normal,” and perhaps it was. But for the first time in my life, I had minimal eye strain while reading, and what I was taking in seemed to “stick” a little better.

That was the show for me. Sure, having better shoulder mobility is cool, but the fact that I can read more efficiently? Amazon will for sure stay in business now.

Aka my life, seriously.
Aka my life, seriously.

An Unreal Day 2

 So that ended my day treatment. I had upcoming 2 prescriptions for glasses, a splint, and some exercises to do.

But what exercises did Ron Hruska give? What will Zac’s splint look like? All will be answered in part 3.

Is it 90/90 hip lift? An adductor pullback? Early left stance?
Is it 90/90 hip lift? An adductor pullback? Early left stance?


Treatment at the Hruska Clinic – Initial Evaluation

For part 2, click here.

For part 3, click here.

“Do you produce enough saliva?”

That was the first interview question Ron Hruska asked me; something I will never forget.

No worries, I do.
No worries, I do.

I went to Lincoln, NE for almost a week to take a course, get treated, and observe PRI in it’s purest form.

I wanted to see Ron out of curiosity and because I cannot achieve neutrality on my own. I have done most every exercise that could be thought of and been “worked on” by my fellow comrades and a couple PRI instructors in courses; nothing could budge.

I knew I needed some type of orthotic to get somewhere; the question was which one?

Subjective Complaints

I do not have any pain really. My only complaints are a tight neck and I can’t seem to deadlift without feeling most of the effort in my back.

I don’t see this deadlifting problem as a form issue necessarily. Interning with Bill Hartman at IFAST cleaned that up, and for a long time I could feel glutes and hamstrings all day when I deadlift.

After each great pull, this occurred.
After each great pull, this occurred.

But not now.

Other “issues” I have

  • Left TMJ clicks; nonpainful.
  • Clench jaw at night.
  • Eye strain after reading on a computer too long (duh).

By PRI standards, I am a classic PEC. I have no pathology anywhere, but I am limited in almost every motion.  I knew this and so did Ron.

Objective Exam

 First Ron had me walk and was pointing out some things to my student-to-be Trevor, and then got me up on the table to check my hips.

“Here’s your problem.”

My hip external rotation was about 70 degrees on the left, 40 on the right.  He then checked my hip abduction, which was a solid 30 degrees bilaterally.  The next test followed in a logical progression…

He gloved up and checked my bite.

Sort of what's going on with my cranium.
Sort of what’s going on with my cranium.

He noted I had a type I occlusion bilaterally and noticed my chipped front tooth. He wanted to show me which tooth was grinding on that, so he asked me to move my jaw forward.

I couldn’t do it.

He gave me a mirror to help see what I was trying to do.

I couldn’t do it.

He put a towel over my eyes and dimmed the room.

I easily contact my front teeth, gain 30 degrees of hip abduction on both sides, had equal hip external rotation, and for the first time ever had a negative thomas test.

We figured out what I needed.

For realzzz
For realzzz

The Needed Orthotics

Ron concluded that I was a tongue thruster, had a very narrow/crowded mouth, and my visual system was patterned enough to drive my nervous system into extension. He also explained, which blew my mind, that a reason I always put my hands in my pockets is to provide a reference center for my very active hip flexors.

My right hand is my TFL, my left hand is my psoas.

And here I thought my other one was giving a high five.
And here I thought my other one was giving a high five.

The next process was to contact his dentist to fit me for a Gelb splint and set me up with a day at PRI vision.

Before chatting with the dentist, he checked my mouth one more time just to make sure he had all the information he wanted to say. It was this second look that Ron noticed that I still have my wisdom teeth.

“How far do you want to get into this?”

Stay tuned for day 2.


Stupid bunions! Oh sorry wrong course.
Stupid bunions! Oh sorry wrong course.

For part 2, click here

Course Notes: PRI Vision Postural Visual Integration


I am still picking up the white matter that exploded all over the pavement as I left the PRI Vision course that was hosted in Grayslake, IL.

It was an excellent experience interacting with Ron and Heidi, and believe it or not they are familiar with my blog…and the corresponding pictures.

Such as this one with all the cool kids.
Ron did win the Oscar

Therefore I was the butt of many jokes this past weekend, which definitely made me feel at home with the PRI family that I have so grown fond of.

There is a reason it has taken me so long to put this work up. These notes have been the most challenging I have written yet, as the material was way out of what I have normally been studying.

It is this class however, that solidifies PRI methodology as grounded in neurology. It was two days of brain, autonomics, vision, and optometry. I will do my best to show you what I learned in a semi-understandable manner.

But we know what Sean Connery says about your best.
But we know what Sean Connery says about your best.

Seeing Visions

Definition – “The deriving of meaning and the directing of action as a product of the processing of information triggered by a selected band of radiant energy.” – Robert Kraskin

Vision is not just what we see, it is what drives us to make decisions.  It is a skill that we develop as we age. It is the dominant sense in the brain, as 70% of the brains connections are related to vision.

Vision can and does become lateralized.

Sight is the clarity of our visual field, which is slightly different from vision. Having more clarity is not necessarily better, as there are many things that we see that we do not take into account and process.

Think about when you get a new car. How often are you now seeing your car brand when you drive compared to before? This realization occurs because your brain has informed your visual system to become more aware of the brand in question.  The desire for a particular behavior drives what information we take in from the environment.

Our environment influences our behavior, and our behavior influences our environment.

New product cover sneak preview....Kidding aside, I'm excited to see CW's product.
New product cover sneak preview….Kidding aside, I’m excited to see CW’s product.

Pluses, Minuses, and other Fun Things

 There are several visual concepts that PRI has integrated into its methodology. You need to know this stuff to understand further concepts.

  • Myopia (nearsighted): See better near as space is constricted and leads to system-wide extension.
  • Hyperopia (farsighted): See better far than near. Space expands and leads to system flexibility at low levels.
  • Astigmatism (aka scoliosis of the eyeball): Details are distorted in one direction more than others due to asymmetrical torque on the eyeball.
  • Presbyopia: The lens cannot focus as well due to normal lost flexibility as we age.
  • Accommodation: Ciliary muscle tightens to focus on close objects. Chronic over-accommodation may create artificial myopia because it becomes hard to turn off the ciliary muscle (like contracting a bicep all day then trying to relax).
  • Ambient visual pathway: Seeing the periphery.
  • Focal Visual Pathway: Seeing detail, clarity.
  • Convergence: Eyes move inward to close on a target.  Associated with extension and “tightness.”
  • Divergence: Eyes move away from each other to watch a target move far away. If excessive, reflects system instability; possibly hypermobility somewhere.

Visual Goals
In PRI Vision-land, the goal is to maximize space and centering to establish alternating and reciprocal activity. You could also call this gait.

When our brain drives us into a right lateralized pattern, typically our eyes accommodate to best perceive the environment. The left eye becomes more focal, and the right eye likes to be more ambient.  This unilateral functioning leads to less left-sided visual space perception.

If I do not need to perceive as much space, this could reflect positioning of the rest of the body. I do not need as many planes or positions to move in when I have less environment to survive in. If I become myopic and only need a small space to live in, I will extend because I only need the sagittal plane to survive in that confined space.

If this makes up most of your life, you probably don't need frontal and transverse.
Here we see the sagittal animals in their natural habitat.

The brain wants visual space and kinesthetic input to match, and will make the necessary accommodations for that to occur. These accommodations at the neck in particular include right upper cervical sidebending and left lower cervical rotation.

To maximize space, the goal would be to reverse the function of the eyes. How do we do that? A simple way, like all other PRI techniques, we drive someone left.

Ron simply demonstrated this change by improving passive hip abduction by 30-degrees after educating a classmate just to become aware of her left hand. He maximized her left space.

Take away: Become more aware of objects on the left side. Learn to love the left environment

We also want our folks to be able to center. This concept reflects a balance between top-down and bottom-up influences on position.  Basically, we want to be able to maximize support from the floor while using appropriate visual perception.

In one who is first neutral, the eyes have to move independently of the head and neck in left stance. If one leans or lists, barring potential below-neck impairments have been addressed, then they are likely either using the visual system to hold themselves upright or have a vestibular problem.

Heads, Bodies, and Necks  (Oh My)

Many of the above concepts occur by differentiating eye, head, neck, and body movements. Ron and Heidi discussed many different reaction types to illustrate vision’s connection to other body movements.

Head on Body Righting Reaction (HOB) – The goal is to be able to have the head and neck move independently of the body. If limited, head and neck have limited mobility in right side bending, flexion, and left rotation.  The head, neck, and body move as one unit.

Neck on Body Righting Reaction (NOB) – Turn the neck and the body follows. This is a primitive reflex that ought to drop off around the age of three. If not, then the neck is running the body’s position.

Body on Head Righting Reaction (BOH) – Turn the body and the head follows, indicating feet have no input into body righting.  The neck matches the body in terms of rigidity and extension.

Body on Body Righting Reactions (BOB): The body has the capacity to regulate itself with contact from the ground and without HOB or BOH reliance.

Talking about BOB way before PRI started teaching it.
Outkast talked about BOB way before PRI started teaching it.

In PRI Vision, we want to maximize HOB and BOB to the best of our capacity.  We want to take ascending input from the body and react without descending reliance from the head and neck.

Visual Neutrality

To constitute the visual system being neutral, we need to develop the following qualities:

  • The right eye needs increased focal dominance.
  • The left eye needs more peripheral vision.
  • A not too excessive astigmatism correction.
  • Accurate binocular alignment at distance (both eyes working together); with the capacity to tolerate slight changes in convergence/divergence.
  • Flexibility between seeing close and far.

The flexibility to see close and far actually ties to a very huge PRI concept, the ZOA. This time, however, we are not talking about a zone of apposition. We are talking about the Zone of Asymptote.

Those not familiar with an asymptote, we are dealing with this picture below.


Neutrality not only of the visual system, but the entire human system, runs in this fashion. We never truly reach total neutrality; only approach it [0]. Instead, we alternate between progressive flexion (top right) and extension (bottom left), parasympathetic (top right) and sympathetic (bottom left), depending on what is required to perform a task. Going too far in either direction is when we run into problems.

We can test this neutrality with many of the previous PRI assessments I have outlined. What is new to this course is the upper cervical sidebend (normally limited right), and then a few standing tests to assess some of these reactions in three planes. I won’t go into detail on these tests because they involve visual intervention…and because I can’t do them 🙂


Patients are classified into 3 different levels (1, 2, 3), with each level indicating a progressively more unstable/unpredictable visual system.

Level 1 folks typically present with more basic aches and pains, and have impaired HOB reactions.  Treating these patients requires emphasis on visual accommodation by altering the space they perceive.  This training will allow for vision that does not require cervical stability.

Level 2 may have scoliosis or whiplash, and dizziness-symptoms. These folks usually have some instability somewhere in the system.  These patients would be considered NOB.  Treatment emphasizes sensory and proprioceptive accommodation by finding and feeling reference centers on a stable visual system.

Level 3 patients typically have a history of head trauma or spine/eye surgery. These patients need to maximize both visual and sensory accommodation, as well as be able to alternate between the two.  These patients must maximize both bottom-up and top-down inputs.

To a certain extent therapists and other clinicians can affect the visual system, but this depends on how far along the pattern one is. If too far, an optometrist will likely need to be involved.  These patients have failed to become fully neutral by all other PRI interventions.

With an optometrist providing the visual references, the clinician takes the patient through three training phases.

Each phase progressively challenges the interaction among the visual system, body, and environment.  A lot of the training involves simple daily reminders such as maximizing peripheral vision, planting feet when turning head, not looking at the ground, physical activity with PRI glasses on, focusing on arm swing, etc.

I also picked up a couple exercises that I think could be beneficial regardless of a visual problem.  The first activity helps develop HOB reactions by differentiating eye and head movement.

 The next exercise is an excellent technique for helping someone feel the ground. This goal can be met by creating less ground to contact via a narrow board.

 Conclusive Pearls for the Girls

Just like all other systems, the visual system naturally tends toward a certain asymmetry that many of us must battle against to maximize triplanar movement and autonomic balance. 

The biggest pickup from this class was the need for interdisciplinary care. I sometimes fall into a pattern in which I think I should be able to provide the necessary skills to help just about everyone, but PRI Vision gave me a reality check.

We can only help someone insofar as are scope and skill-set allows. Perhaps there shall be a day where having multiple disciplines working in the same room with someone will be the norm.

Until then, I’ll be looking to make friends with an optometrist.

Other Random Factoids

  • Infants only see black and white; therefore good developmental toys should only be black and white.
  • Vision is guided by gross motor until age 4, then vision guides gross motor. If a child works predominately on screens at this age, they miss out on manipulating space because screens are only 2-dimensional. Could possibly affect visuomotor output.

Very Wise Heidi quotes

  • “Just because you have it [vision] doesn’t mean you use it like you could.”
  • “The path of least resistance for the brain is the pattern.”
  • “The position you are in is determined by the space your brain thinks you are in.”
  • “The brain tells what the eyes to look for.”
  • “Vision is more than sight, it’s a system.”

In(famous) Ron Quotes

  • [To me as I clicked my pen] “Please don’t tweet that.”
  • “Humans are pretty cool.”
  • “It’s not me who is the problem. It’s the environment.”
  • “Near-sightedness is a disease.”
  • “You can develop strength very well if you keep yourself limited.”
  • “The biggest adjustor to your illusions is your neck. Your neck is your identity.”
  • “The brain selects what it wants to see based on patterns.”
  • “The brain tells your eyes what to do. The eye is the conduit to the soul.”
  • “The eye is the biggest diaphragm you’ll ever have.”
  • “If there is a muscle spindle the autonomic nervous system is involved.”
  • “A rehab setting is the basketball court.”
  • “You all have a form of chiari syndrome.”
  • “If you use your neck your primitive reflexes are still on.”
  • “I think we killed that.”
  • “You right AF IR alwaysbes. You left AF IR wannabes. “
  • “I’d rather have you leave on the right side than confused.”
  • “How does it feel knowing the optometrist in the room is turning muscle on faster than any E-Stim unit?”
  • “Giving someone monovision is the most horrible thing someone can do.”
  • “Idiopathic scoliosis is autonomics. Tweet that.”
  • “We were meant to get bumped and bruised.”
  • “The best Pilates instructor you ever had was a primitive reflex.”
  • “Am I doing this for Medicare reimbursement? Bleh.”
  • “Put a contact lens on your left butt.”
  • “You weren’t meant to be on this Earth to be facilitated. You were meant to be on this Earth to be inhibited. That’s what laws are for. Tweet  that. Personally, I’m here to tweet you!.”
  • “If you fail, you treat your patient.”
  • “We spend more time defending than we do treating.”
  • “We all have natural limitations.  They’re called labrums.”


And that's how Heidi prevented Ron from doing another dog impersonation.
Found out about the dog impersonation.

PRI and Pain Science: Yes You Can Do It


You may have noticed that my blogging frequency has been a little slower than the usual, and I would like to apologize for that. I am in the midst of creating my first course that I am presenting to my coworkers. It has been a very exciting yet time-consuming process. It makes me excited and more motivated to someday start teaching more on the reg.

Ever since I started blogging people started asking me questions. These range from many topics regarding physical therapy, career advice, and the like. Some of the more frequent ones include:

  1. What courses should I look at?
  2. Any advice for a new grad?
  3. Seriously, Bane. What’s the deal?
Some questions are best left unanswered.
Some questions are best left unanswered brother.

But the one I get asked more often then not is as follows:

“Zac, how do you integrate PRI into a pain science model?”

A great question indeed, especially to those who are relatively unfamiliar with PRI. With all the HG, GH, AF, FA, and FU’s, it’s easy to get lost in the anatomical explanations.

Hell, the company even has the word (gasp) “posture” in the title. Surely they cannot think that posture and pain are correlated.

One of my favorite actors of all time. RIP
One of my favorite actors of all time. RIP

I think there is a lot of misinformation regarding PRI’s methodology and framework. What needs to be understood is that PRI is a systematic, biopsychosocial approach that predominately (though not exclusively) deals with the autonomic nervous system. The ANS is very much linked into pain states, though not a causative factor.

But of course, that may not be enough. Perhaps we can dig a little deeper into what may be going on. My hope with this blog is to make a guide to integrating two very effective paradigms which I feel are not mutually exclusive.

PRI Patterns and Nociception

 David Butler discusses many nociceptive processes, including mechanically-induced pain, inflammation, and ischemia.

I feel that the PRI patterns, albeit normal, could contribute to nociceptive processes. Mechanical pain makes the most sense. We could think of this process as typical anatomy/biomechanics. If one is in a right-lateralized and extended position, certain areas are going to be more prone to mechanical deformation than others.

Inflammatory processes could be caused by acute injuries secondary to position. The easiest example I could give would be an ankle sprain. If someone is in a right lateralized pattern (a la Left AIC), the right ankle/foot complex would be more supinated, thus being more at risk to sustain an ankle sprain. So in these cases, a right lateralized pattern could be one of many risk factors for leading to an injury.

Ischemic nociception is where things get interesting. There are two ischemic features that Butler mentions in “The Sensitive Nervous System” that stood out to me:

  1. Symptoms after prolonged or unusual postures.
  2. Rapid ease of symptoms after a change of posture.

If I am right lateralized and unable to leave right stance, this position could become ischemic after a prolonged period. Less movement, less axoplamsic activity, less blood flow.

You can't feel the flow when you can't move.
You can’t feel the flow when you can’t move.

Moreover, symptoms would be much more challenging to relieve. If I am unable to adduct and internally rotate my hip maximally, then I effectively limit what movement planes I am capable of utilizing. This concept is what Bill Hartman calls movement variability. When a position becomes nociceptive, movement must occur to reduce danger signals and restore axoplasmic and blood flow. I am looking for freedom. But triplanar activity is unachievable, movement freedom becomes a limited resource.

I simply lose the ability to change posture, which limits my ability to relieve ischemia.

 PRI Patterns and Peripheral Neuropathic Pain

 When I am in right or left stance, the nervous system slides and glides to accommodate position. Suppose I am in right stance. Right stance would require my right hip to be more extended, adducted, and internally rotated. My left hip would be flexed, abducted, and externally rotated.

When my hips are positioned as above, the sciatic nerve would be more taut on the right and slacked on the left. Now if I never leave right stance (aka left AIC), then I could potentially be more at risk for tension impairments on the right.

Another example would involve spinal position. Research demonstrates that humans have a naturally right oriented spine (here & here) which is precisely what PRI advocates. This orientation may bias more compression on the right nerve root than the left. If we have someone who presents with a dominant PEC i.e. spinal hyperextension, we could potentially see increased compression bilaterally.

Here we go yo, it's just a potential scenario.
Here we go yo, it’s just a potential scenario.

PRI, What a Great Defense

Now of course, we know very well that nociception and peripheral neuropathic issues are neither necessary nor sufficient for a pain experience. So how does PRI relate to pain?

Simple, the PRI patterns are the perfect protective postures for us to assume when we are threatened.

We drive these patterns via our autonomic nervous system. If you read Stephen Porges work, he discusses the concept of neuroception. Neuroception is how our nervous system’s evaluates risk. We take all sensory information in regarding our environment and determine if we should fight, flight, freeze, or relax and socialize.

When we neurocept (is that a word??) something as a threat, we will become more sympathetically driven and likely use our most efficient processes to respond to the threat. We use what we know.

Play Scrabble with me and you'll find I make up words all the time.
Play Scrabble with me and you’ll find I make up words all the time.

We bias ourselves to the right because motor planning occurs in the left hemisphere regardless of hand-dominance. If I stand on my right leg, I simply am better able to make my next move than if I were to stand on my left.

We will increase activity of our anti-gravity muscles, our extensors. To defend against a threat, it probably makes sense to stay upright. This function has governors present in the reticular formation. The pontine reticulospinal tract controls extensor tone, and the medullary reticulospinal tract inhibits this tone. One of these is spontaneously active and the other is not. Guess which one? Extension is the norm to keep upright. Thus, extensor tone is the brain’s reflex-driven path of least resistance. Perhaps if I am under threat long enough, I become a PEC?

Breathing will become faster and shallower. Take a look at the diaphragm. Which side is larger?

Would you look at that.
Would you look at that.

The right hemidiaphragm is larger and more powerful than the left. If I am already biased to the right and have a stronger muscle on the right, breathing becomes a less conscious process.

My point of listing these plausible changes in response to theat is to demonstrate that we are fairly similar creatures. Bill again, helped me realize this on a post he made at Somasimple.

If a lion were to walk in the room, what physiological changes would we undergo? Our heart rate would increase, pupils would dilate, HRV decreases, we sweat, etc. Are these responses not the same for all humans? These physiological changes are a common human pattern. Could it be possible there is a common threat response in postural and muscular activity as well? This pattern of positioning and neurological bias is what I feel PRI has put together more completely than anyone else.

Granted, we can still account for individual differences, but realize these changes are likely minor variations off the normal response.

When under threat, your heart rate increases 20 beats per minute, mine increases 10.

When under threat, your sweat accumulates on your brow, mine on my palms.

When under threat, your left anterior hip capsule becomes lax via compensatory external rotation, mine stays intact after compensatory external rotation.

Similar responses occur through varying degrees.

We're not so different, you and I.
We’re not so different, you and I.

Treating Pain Through PRI Approaches

I think PRI can influence the pain experience by altering autonomics via the vagus nerve. Paced breathing can positively influence pain states, and PRI breathing-style is very much paced.

The positions utilized are the farthest removed from the typical protective response when we perceive threat. If right stance with increased extension is what we do when we are threatened, then I am going to get you into left stance and flex you until the cows come home.

PRI essentially is graded exposure into left stance and parasympathetic paradise.

That doesn’t mean that PRI is going to eliminate the entire pain experience in all cases. There are some people who have injuries that are producing nociception, and may take time to heal. There are some people who have enough neural sensitivity requiring a hands-on or neurodynamic approach. There are some people who have centrally-maintained pain experience that requires graded exposure, pacing, and homuncular refreshments. The autonomic protective response is one piece of the puzzle, and altering that piece is the only way one can know if it is contributing to one’s complaint.

Therapeutic Neuroscience Education…PRI Style

So usually when I educate patients I just run through the above as quickly as possible…

download (2)

Okay that’s not 100% true.

I actually use the concept of a home security system to explain how PRI patterns are a part of the pain experience. Go ahead, watch the video, I’ll wait.

So as you can see, I do not go into nitty gritty detail of PRI methodology. It is mostly not necessary and could potentially increase threat perception. But framing the system as done above can help the patient understand why we may work at areas far away from the pain experience. We are treating what area of the system continues driving the protective response. We are treating the person.

In Summation

PRI is a very powerful system that does not have to go against current pain research, not that it ever did. But the above may be a potential framework and justification as to how PRI affects the pain experience.  It is the framework that I operate on, and will continue operating on until I am shown otherwise.

I hope that I am.

Who knows where the rabbit hole goes next.
Who knows where the rabbit hole goes next.