I had learned so much about what they do in PRI vision that I was feeling somewhat okay with implementation.
Then my friends told me about the updates they made in this course.
I signed up as quickly as possibly, and am glad I did. This course has reached a near-perfect flow and the challenging material is much more digestible.
Don’t expect to know the what’s and how’s of Ron and Heidi’s operation. And realistically, you probably don’t need to.
Your job as a clinician is to take advantage of what the visual system can do, implement that into a movement program, and refer out as needed. This blog will try to explain the connection between these two systems.
If you want more of the nitty-gritty programming, I strongly recommend reading my first round with this course. Otherwise, you might be a little lost.
Note: I made some errors on the first rendition of this blog that were corrected after speaking with Eric Oetter. Courtesy to him, Lori Thomsen, and Ron Hruska for cleaning up some concepts.
Four Months Later
When the Lori Thomsen says to come to Cervical Revolution, you kinda have to listen.
I was slightly hesitant to attend since I had taken this course back in January. I mean, it was only the 3rd course rendition. How much could have changed?
Holy schnikes! It is simply amazing what four months of polishing can do. It was as though I attended a completely different course. Did I get it all figured out? No. But the clarity gained this weekend left me feeling a lot better about this very complex material.
This is a course that will only continue to get better with time; if you have a chance to attend please do.
Let’s now have a moment of clarity.
The craniocervical region is the most mobile section of the vertebral column.
This mobility allows regional sensorimotor receptors to provide the brain accurate information on occipital position and movement.
The neck moves with particular biomechanics. Fryette’s laws suggest that the cervical spine produces ipsilateral spinal coupling in rotation and sidebending. The OA joint, on the other hand, couples contralaterally.
C2 is the regulator of cervical spine motion; much like the first rib regulates rib cage movement.
C2 is also important for the mandible, as it balances the cervical spine during mandibular opening. The reason this occurs is because the mandible and C2 are at the same fulcrum level.
Often triplanar motion will decrease amidst progressive respiratory demand or threat. These changes help promote neck stability while simultaneously increasing demand on the mandibular elevators, extraocular muscles, and vestibular system
If these changes occurs long enough, sensory issues may become prominent.
Stability can occur through increased sagittal plane activity in the upper cervical spine and cranium either one of two ways:
O on A via posterior cranial rotation
A on O via forward head posture
Both strategies attempt to flex the cranium, but both are undesirable if occurring underneath a lost cervical lordosis.
OA hyperflexion is often seen in those who sit in front of monitors for long periods of time. The visual system helps promote stability.
OA Hyperextension is an attempt to create an airway. Cranial protrusion may be utilized as a way to open up the airway under stable conditions. This position passively raises the hyoid bone, which often depresses when one uses a mouth-breathing strategy. These individuals rely heavily on the dentition for craniocervical awareness.
Of course, these are not the only ways undesirable neck stability can occur.
You might have a stable neck if:
You have a narrow palate.
You have a cross bite.
You have a narrow airway.
Patterned Mechanics 3037
The TMCC is the foundational polyarticular muscle chain at the neck, with the right side generally more active than the left.
The normal RTMCC pattern presents with the following at the neck:
C2-C7 orientation in the transverse and frontal plane to the right, with compensatory rotation and sidebending to the left.
The OA joint is sidebent to the right and rotated left as a passive orientation.
The RTMCC may be present in isolation or with various cranial strains.
A cranial strain may occur if the left SCM sidebends the OA left within the RTMCC pattern. This compensatory movement occurs to attempt to reduce OA rotation and upper cervical strain.
If you weren’t sleeping during the biomechanics section, you will notice that this goes against Fryette’s laws. In order for this compensatory strategy to occur, the right alar ligament and posterior capitis muscle must become lax. This movement does help reduce torsion and compression on the upper cervical segments, but may create a cranial lesion in the process.
This compensatory movement is a precursor to a left sidebending cranial lesion, and this lesion along with others are quite prominent.
According to a 2008 study by Timoshkin and Sandhouse, 72% of individuals have a cranium that is in a sidebend or torsion pattern; with left sidebend and right torsion being the most common.
Of those two cranial strains, the left sidebend will be the most common. Let’s dive into that pattern more.
Left sidebend (LSB)
The LSB lesion is named for the sphenoid’s greater wing position. In this case, the greater wing is high on the right and low on the left. The occiput matches this orientation.
Where these bones will differ occurs about a vertical axis; as the sphenoid externally rotates while the occiput internally rotates.
The mechanical change at the atlas drives this position. The sphenoid just goes along for the ride.
A prime example of this cranial strain would be the lovely Garey Busey.
Right Torsion (RT)
RT’s also have a low left greater wing of the sphenoid, but the big difference is at the sphenobasilar joint.
Since the RT is a progression from the LSB, the occiput will attempt to sidebend right to level occipital position. Since the sphenoid stays in position, torsion through the sphenobasilar joint occurs.
This twist is driven by the sphenoid as means to create pseudo-facial symmetry via extension.
Lorimer Moseley is actually a perfect example of this type of cranial position, as many facial features are flipped from a LSB face.
This is a Test
The only way to truly determine which cranial strain one has is through imaging, but PRI testing can guide us down a treatment path.
Admittedly, the cervical tests are not the most reliable of the PRI bunch. To attempt to offset this limitation, we shall imply a test battery to determine position.
There are four essential tests in the TMCC algorithm:
Cervical extension: Checks cervical lordosis presence; goal is 30-35 degrees.
If limitations are present it is likely that SCM hyperactivity is reducing the normal lordotic curve.
I think of this test as the extension drop test of the cranium. It tells you if you are working with someone who is sagittally lax or not.
Cervical axial rotation: Checking C7-T1 rotation, which reflects C2 position. Looking for symmetry at about 30-35 degrees of movement. This test determines the TMCC pattern.
Limitations will be present due to the cervical spine’s compensatory rotation and sidebend to the left. Placing the patient supine on a table rotates the spine further to the left, which places a RTMCC patterned neck in an end-range position. Hence, normally left cervical axial rotation is limited. We would see bilateral limitations in a BTMCC.
When performing this test you want to make sure that you do not give the patient a lordosis, for this can create false negatives.
Midcervical sidebending: I think of this test as the great comparer between the cervical spine and the cranium. Looking for symmetry at about 30-35 degrees. This test gives you a frame of reference for our next test.
In the RTMCC pattern, this test is limited to the right secondary to an arthrokinematic block. If the cervical spine is rotated left on the table, the neck cannot sidebend to the right. That’s Fryette’s laws brah!
OA sidebending: This test looks at cranial position. Looking for 8-10 degrees bilaterally.
More than 10 degrees of sidebending would indicate alar ligamentous laxity.
A RTMCC individual would have limited right OA sidebending due to a bony block. In someone with a LSB however, you would have limited L OA sidebending because the left SCM pulls the OA over to the left. A RT could present with just about anything, as pathology is quite prominent in these folks.
RTMCC repositioning and retraining goes about the following progression:
Cervical spine → OA joint → Mandible
The neck is the top priority because its mobility maximizes cranial sensory activity.
Moreover, most cranial activities are integrated multi-joint movements. Spending time doing “basic” PRI sets the foundation for one to combine complex movements.
Mandibular movement is often normalized by the time the neck is cleared. The reason TMJ mobility may be limited because of craniomandibular discord.
In the RTMCC pattern, the right lateral pterygoid works with the right anterior capitis and right SCM to deviate the temporal bone and mandible to the left whilst the occiput (and sphenoid) are “stuck” in the left sidebend position. In a neutral system, we would expect the occiput and sphenoid to move to the right during this cranial movement. This tonal issue could limit mandibular movement.
Thus, a neutral cranium often restores normal TMJ mechanics. If problems still arise, then mandibular re-education may be necessary.
Sometimes you need a Dentist
Of the two common cranial strains, RTs will most likely need integration.
With normal occlusion, one side of teeth should touch while the other discludes. This alternation creates lateral shifting in both the mandible and the cranium.
The canine teeth act as guides for where the jaw ought to be in space. When canines touch during shifting, molar contact follows as the teeth drop into position. This action is called group function.
If group function cannot occur, it is likely that a dentist may need to be involved.
Splint therapy is generally recommended in these cases. More specifically, mandibular splints are the go-to (which I spoke about here and here).
Maxillary splints are generally the devil. These splints tend to increase tongue activity and mandibular clenching to hold the splint in. The one major case that may warrant a maxillary splint is the presence of tori.
Even if not using PRI splints, there are four essential pieces needed from a dentist:
Don’t lock the mouth into a position.
Move head back and jaw forward with canines.
Feel one side occlude while the other side discludes.
Have group function and anterior guidance between incisors.
Note – anterior guidance is when the incisors touch the molars disclude
You might be wondering how I educate people about this stuff in a nonthreatening fashion. I got this neat little tidbit from the Ronimal:
“Periodontal ligaments are so sensitive that a hair will throw off your gait.” ~ Ron Hruska
Think about that statement the next time you get something stuck in your teeth. Drives you crazy right? If there is something undesirable going on with your teeth, you will know about it in some way. Some output will occur.
Moreover, think about what occurs at the dentition when stressed. Do you clench? Reducing this muscle over activity by splint therapy introduces a salient stimulus that could reduce the stress response, if the craniocervical region is involved.
Hint: It usually is.
Infamous Ron Quotes
“Every single bunion and ACL patient is a TMD patient.”
“I love dentistry, but I don’t like dentistry, but I like dentistry.”
“You cannot treat a neck if a neck can’t treat itself.”
“We are a product of how we move our cranium.”
“A bra strap will really mess a tongue up.”
“The worst thing you can do to a patient is splint their neck.”
“We still have a lot of goniometric minds.”
“What good is the polyvagal theory if you don’t understand the neck.”
“Don Neumann is the best book for 1% of the population.”
“Treatment starts when you appreciate frontal plane.”
“How can you treat a TMJ if you can’t control the T?”
“The vehicle you drive is not the problem, it’s the path your on.”
“A twisted levator is an untwisted neck.”
“Hallelujah you have a pattern.”
“When you lose your left ab wall the head and neck will pick up the slack.”
“You can learn a lot about cognition and personality if you look at a neck.”
“You can’t feel CSF flow if you lack a cervical lordosis.”
“Make sense out of sense.”
“A neck that can’t move will produce a cant.”
“Crossbites, pulled bicuspids, and high arches scare me.”
“Sedentary lifestyle and screens demand we go straight.”
You know how sometimes when you are treating someone that individual eventually reveals fairly important information that he or she forgot about.
Yeah that was totally me.
I’ve always had a stuffy nose as far back as I can remember; especially in the winter. The only time breathing felt incredibly easy was when I was eating paleo in college. I have progressively been losing my sense of smell as well.
Must be old age right?
When I spoke with Lori Thomsen about my recent experience, she mentioned at Pelvis that attaining neutrality in certain areas but not others could lead to a “pressure cooker” phenomenon. For example, if I have someone with a neutral neck and thorax, lower extremity symptoms may possibly be more common.
In my case, I had a neutral pelvis at the time my wisdom teeth were pulled. Pull out wisdom teeth and my nasal airway goes crazy. Guess where the pressure went?
It was time to see an ENT.
After viewing my CT scan and airway, my ENT concluded I have patho-scoliosis.
More specifically, airway scoliosis. He found a deviated septum and some enlarged turbinates. These two factors could have a large impact on my breathing capabilities.
To me this made a lot of sense. If you read this article, a nostril will drive air to the ipsilateral lung. So depending on what nasal airway is blocked may dictate whether I am a Right BC or a superior T4.
Moreover, sensory information through the nose travels to the contralateral hemisphere. In my case, my left airway is a bit more open than my right, which would increase sensory input to my right hemisphere.
Per the RTMCC pattern, I actually should have a more open right airway. So this finding would be considered patho per PRI standards. Hence the pathoscoliosis.
Could this abnormality be a contributing factor as to why I am solid on my left side but struggle when I go back to my right? Or even why I’m left-handed? Purely theoretical of course, but something I play around with in my head. I think weird shit like that.
Surgery is not the first line of defense, so we started with conservative measures. I was given a nasal saline rinse and couple nasal sprays to reduce inflammation and symptoms.
Let me tell you, I could notice a difference with the first rinse.
The very first nasal rinse treatment opened up a whole new world for me. I cleaned out the sinuses and immediately measured my horizontal abduction:
20 degrees to 45.
I think I found a new repositioning technique.
The coolest thing? I could smell again. It’s amazing the scents in my apartment and the clinic that I could now pickup that I never noticed before. It was an incredibly rich sensory experience. Sleep quality drastically improved within the first couple nights as well.
The only downside was the effects were not long lasting. It was time for phase two.
Nasal Adductor Pullback
About a month later I went back to the ENT and had an allergy test.
The good news is that I am not allergic to any foods. I can eat anything I want (yay). And actually I didn’t have many allergies at all.
The bad news is that I have a large allergy to perennial rye grass, which is extremely common in AZ. I also have a couple allergies to a few other weeds or molds, but nothing major.
The next step is to try immunotherapy to see if I can reduce my sensitivity to these allergens. This basically amounts to me taking oral drops for the next three years. The hope would be that the threat these allergens are to my system would become nonexistent.
I ought to notice some changes over the next 6 months. If not much symptom-wise is changing, surgery to reduce the turbinates and align the septum will be the likely next step.
If only I could tell the ENT that my symptom was limited cervical axial rotation.
Lori is a very good friend of mine, and we happened to have two of our mentees at the course as well. Needless to say it was a fun family get-together.
Lori was absolutely on fire this weekend clearing up concepts for me and she aptly applied the PRI principles on multiple levels. She has a very systematic approach to the course, and is a great person to learn from, especially if you are a PRI noob.
Here were some of the big concepts I shall reflect on. If you want the entire course lowdown, read the first time I took the course here.
Extension = Closing Multiple Systems
This right here is for you nerve heads.
It turns out the pelvis is an incredibly neurologically rich area.
What happens if a drive my pelvis into a position of extension for a prolonged period of time?
I’ve written a lot about how Shacklock teaches closing and opening dysfunctions with the nervous system. An extended position here over time would increase tension brought along the pelvic nerves. Increased tension = decreased bloodflow = sensitivity.
We can’t just limit it to nerves however, the same would occur in the vasculature and lymphatic system. We get stagnation of many vessels.
Perhaps we need to think of extension as system closure; a system closing problem. Flexion will be the solution to open the system.
Pausing after an exhalation gives diaphragms time to ascend. Diaphragmatic ascension maximizes the zone of apposition (ZOA). The better ZOA we have, the less accessory musculature needed to take an adequate breath.
The two important ZOAs needed in this course are at the thoracic and pelvic diaphragms. We want to build synchronicity between these two diaphragms.
The way we do that is through the pelvic inlet.
The inlet links and adequately positions these two diaphragms via internal obliques and transversus abdominis (IO/TA).
To determine how this occurs, we must look at how breathing affects musculature.
This part here was a huge lightbulb moment for me. Muscle lengthening correlates with inhalation, and muscle shortening correlates with exhalation. So to create a stretch in areas you wish to lengthen, you may want to inhale, and to increase muscle contractility, you may with to exhale.
[Note: This is one reason in lifting exhalation is during the concentric phase and inhalation is during the eccentric phase?]
Now lets apply this concept to the pelvic inlet in an extended system. Let’s say the left innominate is forward (a LAIC pattern). My left IO/TA on would be eccentrically lengthened and in a state of inhalation. The left thoracic and pelvic diaphragms would be tonically active and form a v-shape.
This dyssynchrony explains why certain pelvic and thoracic tests correlate. The LAIC pattern suggests that I would not be able to adduct my left hip.
At the pelvis, this would occur because I have a “long” left anterior outlet and “short” posterior outlet.
The outlet and the thorax reflect one another. In this case, my anterior outlet is equivalent to the ipsilateral anterior chest wall and my posterior outlet is equivalent to the posterior mediastinum.
Guess what the tests will look like? I will have good left apical expansion and limited left posterior mediastinum expansion. I can’t adduct my left thorax or abduct my right thorax, much like I can’t adduct my left hip or abduct my right hip. These tests look at the same thing the pelvic tests do.
The Definitive Word on PRI Squatting
We can look at one’s ability to actively synchronize the thoracic and pelvic diaphragms by one’s ability to squat.
The functional squat test is an excellent way to show if one is capable of maximal pelvic diaphragm ascension and can shut off extensor tone. It also is a test to see if one has a patho-compensatory pelvic floor; for if you can squat but can’t adduct your hips, you gotz problems.
Here is what the functional squat test is not: a position to go under load in the weight room.
The above was straight out of Lori’s mouth. So to all the people who talk smack about the PRI squat, your answer is above. It’s not looking at the same thing as a max effort back squat.
Here’s how to test it.
Sitting is Hahhhd
In PRI land, sitting is the most challenging position to be in.
Why? Because there are less points which one can reference. Sitting unsupported requires proprioception exclusively on your ischial tuberosities. Success here relies on alternating and reciprocal muscle recruitment. If I don’t have this, I will extend.
Some Quick Postural Eyes
Lori is a great at predicting how dynamic movements will look on the table. Here were a couple things that stood out to me in this regard, as well as a couple other random things.
Leg whipping means an individual likely has a femur stuck in adduction.
Patho-compensatory people usually have more narrow hips. Could possibly be more common in males for this reason.
People who lean to one side in gait need a glute med.
If one cramps during an exercise, think inhibition. We’d rather shaking.
Glute med is the needed ligamentous muscle if a hip subluxes laterally.
Furniture is made to fit people who are 5’8.
Hard orthotics = overrated. We want a soft heel cup and arch to be used proprioceptively.
“I like to refer to myself as your coach.”
“You can’t work the same muscle in a different position and expect the same outcome.”
“You know I’m going to have to spend some time on this little booger.”
“If you want to give more pelvic instability stretch hamstrings.”
“She trusts me and I make her shake which is all good.”
“PECs cannot breathe to the high moon.”
“Getting neutral is not treatment.”
“Her back needs to go on a holiday.”
“Run with ribs.”
“When you go run, run.”
“We like extension, just not 24 hours a day 7 days a week.”
“If your patients cannot breathe correctly, don’t do a PRI activity. They will fail.”
“Not everyone needs a pair of glasses. Some people need a diaphragm.”
“I’m not a comedian. I’m here to teach you.”
“We’re [the clinician] not in control. We’re just invited to the party.”
“I get excited when I feel my right glute max burn.”
“You gotta get those wisdom teeth pulled.” ~Ron Hruska
By virtue of the dentist I integrate with, the time came. And here are the results.
Zac B.E. (Before Extraction)
So at this point in my life the large HRV gains I initially had were dropping and I was still having some neck tension. Training was feeling so-so.
Test-wise, the videos below show what I look like.
Here’s my squat
And my toe touch.
Upper quadrant tests
And lower quadrant tests
And some cervical movements
My pelvis is consistently neutral and I can shift and squat with the best of ‘em. But I still present with restrictions in my thorax, neck, and mandible (BBC/RTMCC).
These limitations are likely present because of a bony block called wisdom teeth.
As you can see, the maxillary (top side) wisdom teeth limit the excurision of my lateral pterygoids for lateral trusive movements. My hope is by removing these guys I will get access to more frontal plane, which should clean, up my remaining tests.
Operation Extraction: 1/30/15
I enter the room to get prepped for surgery, and the worst possible thing occurs.
Country music is playing.
And I can’t have that!
So I politely ask one of the workers there if we can play something a bit more soothing prior to my surgery.
2pac “I ain’t Mad at Cha” begins playing.
That’s more like it.
I get the IV put in, hear some Juicy by Biggy, and pass out from the Mind Eraser anesthesia. Yes, it was actually called “Mind Eraser”, and yes, I remember nothing.
Like this happening
And definitely not this
But I do remember looking like Marlon Brando for a period of time
What was really cool about the whole experience is how little pain I felt. I probably took 2-3 pain pills at most. I think this is because I was actually excited about having this surgery done, and the reward I was hoping to get far exceeded the nociceptive information I would inevitably receive.
Just goes to show it’s all about threat perception.
Zac A.E. (After Extraction)
I waited to re-measure and assess until 6 weeks later. This way I had to some time to heal and adjust to this new sensory experience. My exercise program basically consisted of squatting, alteranting activity, and mandibular lateral trusion to feel my pterygoids.
The cons are I no longer looking like Marlon Brando, but the pro’s are the mobility gains. Check it out in the vids below.
Here are the standing tests
My upper quadrant tests
Lower quadrant tests
Here are my mandibular movements
And lastly, cervical
Since surgery I’ve been hovering between a right BC and superior T4. I consider myself no longer a TMCC patient because mandibular movement is now fully restored. The thorax position can limit cervical axial rotation.
In terms of how I feel, neck tension has been significantly reduced, especially with jaw movement. The only time I get the tension is when I am training hard or if I am reading/sitting for a real long time.
I also produce a crap-ton more saliva, which comes back to the very first question Ron asked me when I started this process. You don’t know what this stuff will affect.
Consequently, I have noticeably much more phlegm in my saliva and feel way more congested than ever. Sleep quality does not seem as good, as I have generally felt a bit more tired throughout the day.
So what gives? My thought was the wisdom teeth would be the final piece of my PRI quest, but I did not get all the changes I was hoping to get. Was Ron wrong? Did I get less wise for nothing?
The one consistent thing that I am still limited in is the cervical rotation and shoulder horizontal abduction. I am hesitant to perform any pec inhibitory activities because I have been neutral in the past. I don’t want to “stretch” something that doesn’t need stretching.
I look over my 3D CT scan that I got at the dentist office, and one thing stands out. I find my limiting factor:
I recently made the trek to Vermont for the first rendition of PRI’s Cervical Revolution course; a course in which the attendees doubled the population of the entire state.
It was nice to go to the class with a bunch of old friends. You always learn better that way, and I couldn’t have been more excited to get the band back together.
And even more so, I got to meet a lot of good folks for the first time. It was a real treat.
This course was meant to update the former craniocervical mandibular restoration course (which I reviewed here and here), with extra emphasis on the cervical spine and OA joint.
In this blog however, I will not touch much on the cervical spine positioning. I still have several questions regarding the mechanics. Some spots within the manual seemed to be conflicting; the blessing and curse of a first run-through. I will update this piece once I get these points figured out.
That said, the revolution helped fine tune the dental integration process for me. I have been working a bit with a dentist, and I have a bit more insight in terms of what devices they are using for whom.
Let’s go through my big a-ha moments.
The human body is symmetrically asymmetrical. When we have capacity to alternate and reciprocate, we are able to separate the body into parts to form a whole.
If you lack integration, then there are no parts. You have an it. This is how somatosensory smudging works. Lacking parts creates a pattern. A pattern could create a threat to the system, or a threat to the system could create a pattern.
We need to be able to differentiate our parts.
Neck Problems Do Not Exist
The craniocervical region is incredibly mobile for a reason. That reason is to create precision for our sensors: vision, audition, olfaction, respiration, and vestibular sensation. This precision occurs reflexively, whereas other appendages act proprioceptively.
These sensors drive the neck. Losing the ability to sense is what can increase the need for a neck to become stable. And when you can’t move a stable neck, teeth may be one thing you try to use.
In this course, the sensors we focus on are our canines and molars. Canines are transverse-plane antennae; necessary for lateral guidance. Molars, on the other hand, let us know what side we are on (frontal shifting).
Two TMCC Possibilities
Ron spent a much greater amount of time discussing two patterns that were briefly mentioned in previous courses: the left sidebend and right torsion.
These two patterns are possibilities that can occur at the cranium in a right TMCC pattern; and it all depends on what happens at the sphenoid.
The Left Sidebend
The left sidebend pattern is typically what we think of with the RTMCC. The atlas is rotated to the right, the occiput rotated to the left, the sphenoid oriented to the right, and the mandible oriented to the left. This positioning cants the mouth left and upward; creating a counterclockwise facial rotation.
It looks like this:
Test-wise, these individuals are limited in cervical sidebending to the right and axial rotation to the left.
Treatment will consist of developing left sided awareness, especially of occlusion. We want left abs to coactivate with a right SCM to establish neutrality. Here is the base repositioner to do that:
Here is where things get a little crazy. In these individuals the atlas, sphenoid, and mandible are right oriented; with variable positions occurring at the remaining cranial bones. This creates a right mouth cant and a subsequent clockwise facial rotation. This cant begets an over-referenced right sided occlusion which can become difficult to move out of.
It looks like this:
Test-wise these individuals will have bilateral limitations in lateral flexion, yet left axial rotation alone shall be limited.
These individuals will likely need some dental integration due to the over-right lateralized cranial positioning; many of these folks have had craniocervical trauma.
Therapy treatment will involve alternating activity, and here is our repositioner for that:
Splints on Splints
One of the big reasons I took this course again (aside from having a con ed problem) is because I wanted to really iron out who ought to get what splints. I definitely learned a much better appreciation for each splint type PRI recommends, and it was nice to see what new stuff they are using. Here are the big ones.
The PRI MOOO
This splint is the new one PRI is making, which is similar to your typical flat plane splint. The big difference is the anterior portion of the splint is built up to allow for better canine reference. Canines are what allow an individual to twist and turn, so the better we can feel these guys the better triplanar capabilities we will have
Who gets it: RTMCC folks; those who have a hard time finding teeth, more neurologically unstable folks.
The Gelb Splint
This guy is the one I was given. This splint helps bring the mandible slightly forward, creating better craniocervical mobility. There is also a lingual bar to reduce tone on folks with active tongues.
Who gets it: Individuals with narrow bites, active tongues, people who talk a lot throughout the day, one who can protrude the jaw forward, disc issues. Generally people who are fairly stable will get these, as they allow for much more movement freedom compared to the MOOO. Makes sense now why I was given this as I had no patho-compensatory patterns.
This device helps retrude the cranium to improve an airway and is usually worn only at night.
Who gets it: Right torsion patients, those with discal compression, individuals with sleep apnea, prophylactically.
These are the expensive beasts. It is an appliance that is worn around the maxillary and mandibular teeth to promote maxilla expansion and cranial flexion. You will likely need orthodontics after this one, as the teeth have a tendency to move.
Who gets it: Individuals with high palates (bilateral or unilateral), individuals who are very neurologically unstable, excessive disc popping.
So there it is. While it had the first-run bumps, this course’s information is priceless; necessary to truly integrate PRI to it’s fullest potential. Attend, find yourself a dentist, and help some people.
Infamous Ron Quotes
“There is a lot of feet in your mouth.”
“Foramen magnum is life.”
“Upper trap is a thermostat.”
“I want to twist the hell out of you so you can untwist and enjoy life.”
“You will never develop abdominal obliques without lateral pterygoids.”
“Dysautonomia is a bad ebola.”
“I’m no different than your protoplasm.”
“If you like feet you gotta like neck.”
“That’s called vagal sciatica.”
“Is it okay if I produce and Arnold Chiari syndrome on you?”
“The best physical therapists are ones who integrate with other disciplines.”
“The best sensory organ you have is your teeth.”
“Cervical revolution is a gift.”
“If you don’t like your spouse give them a NTI.”
“A hyoid that’s high is a cranium that’s forward.”
“You stretching out a neck is not going to get a cranium to go back.”
“The worst thing you can say to a patient is don’t do it.”
“There is no effectiveness in treating a symptom.”
Mike Cantrell was in my neighborhood to teach Myokinematic Restoration by the folks at PRI.
And I couldn’t resist.
This is the third time I have taken this course, a course I feel I know like the back of my hand, yet Mike gave me several clinical gems that I want to share with y’all.
This post is going to be a quick one. If you want a little more depth, take a look at my previous myokin posts (See James Anderson and Jen Poulin). Or better yet, take a PRI course for cryin’ out loud.
Hip Extension, We Need That Yo.
Sagittal plane is your first piece needed to create triplanar activity. Since this is a lumbopelvic course, we look at getting hip extension as high priority.
If I am unable to extend my hip, here’s what I could try to use to do it:
SI joint compression
Anterior hip laxity
Gastrocnemius and soleus.
We use two tests to see if we have hip extension: adduction drop (modified ober’s test)
and extension drop (Thomas test).
The adduction drop will look at your capacity to get into the sagittal and frontal plane, and the extension drop test will look at your anterior hip ligamentous integrity.
A positive extension drop is a good thing if you are in the LAIC pattern. It means you didn’t overstretch your iliofemoral and pubofemoral ligaments. Well done! The reason why this test is not a hip flexor length test has to do with the femur’s position. In the pattern, the femur is positioned in a state of internal orientation secondary to an anteriorly tipped and forwardly rotated pelvis.
Due to this orientation, the femur must be externally rotated during performance of an extension drop test. This would put the psoas on slack. If you still have a positive test, then we know the anterior hip capsule is intact because that’s the only thing holding the hip up.
We spent a good portion of the day learning about gastrocs. In the LAIC pattern, the right gastroc runs the show as a hip extender AND hip external rotator.
The slight inversion action that the gastrocneumius performs helps pick up the transverse plane slack that the right glute max is malpositioned to do so. This is why the right calf is usually larger than the left.
This test’s pinnacle is the 5/5, to which gives us ground to become alternating and reciprocal warriors.
Just because you can hit 5/5 on both sides does not mean you can alternate well.
I was a prime example in class. Mike had me demonstrate my HAdLT in class, to which I easily hit 5’s on both sides.
Despite my quest towards neutrality, I have not been able to keep good thorax and neck positioning. Thanks wisdom teeth.
So Mike checked my right shoulder internal rotation, to which I had about 70 degrees. Way better than the previous 10 or so degrees I started at.
Then Mike had me perform the left HAdLT, which pushed me into my right hip.
Shoulder internal rotation worsened to 30 degrees.
He then pushed me into my left hip with the HAdLT.
Shoulder internal rotation now 90 degrees.
Even though I can crush the lift test, I do not alternate well because I lose position at other areas.
To truly be an alternating and reciprocal warrior, one must be able to perform alternating activities without losing position anywhere in the body.
Why Can’t I Swing my Right Arm?
In many folks with a LAIC/RBC pattern, you will notice that there is minimal right arm swing. You would think that the right arm would be activity secondary to right lateralization and hemisphere dominance. Not necessarily so though.
Arm swing is dependent on trunk rotation. If the trunk can rotate, then the arms can swing.
In the pattern, it becomes very difficult to rotate the trunk to the right, which mean there is no need for right upper extremity extension. So how about instead we just plaster the arm the side? Not a bad idea.
Crazy Good Cues
To close, Mike is a cueing machine. I picked up three new favorites that we’ve been playing around quite a bit in the clinic.
Press heels down on a chair to decrease TFL. Don’t use a ball because the TFL will attempt to adduct the femur via internal rotation. Then slowly add the ball.
Sigh upon exhalation if you have a patient who is rectus-dominant.
Plantarflex the first big toe to feel the left IC adductor in standing.
“Orthopedic symptoms are the result of bad neurology.”
“Good posture compromises respiratory dynamics.”
“Think before you stretch.”
“Stretching is the equivalent of kicking a horse while pulling on the reins.”
“99% of righties have a left thing.”
“Doesn’t matter what the diagnosis is.”
“Give me sagittal or give me death.”
“Most strength deficits are motor control deficits.”
“Total arc depends on what moment in gait you are in.”
I officially became a Jedi this past December after retaking Advanced Integration and going through the Postural Restoration Certified (PRC) testing.
Both were a wonderful experience in terms of learning new concepts and fine-tuning old ones.
Since I have retaken this course, I will not go into huge detail in terms of the material covered (if you want detail, read last year’s AI notes here, here, here, and here).
Instead, I will reflect on a few concepts that really hit home for me (No, i’m not saying what we did at the PRC)!
Extension is Evolution
Extension is what allowed our brains to develop because it brought us to two legs.
The big extenders: psoas, paravertebrals, lat, QL, capitis
Extension given us more but comes with a cost. As we continue to extend, we increase system demands. Extension will likely be a necessary adaptation to live in the world we are creating.
I’m scared to see what the future looks like.
Refers to triplanar position of the body. Neutrality is the state of rest and transition zone from one side to the other. We want this most of the day, but can’t expect this to occur all day. We want to establish a rhythm in and out of neutrality in alternating and reciprocal function.
The alternating and reciprocal rhythm has alternate appendages on either side of the body. When the left leg is in front, the right leg should be back.
In right stance, the appendages take the following positions:
Legs – right back, left forward
Arms – right forward, left back
SCMs – Right back, left forward
Lateral pterygoids – right forward, left back
Extra-ocular muscles – right back, left forward
In left stance, the above positions are reversed.
Oftentimes one or many of these appendicular positions is flipped. This flipping is when you have defensive patterning (LAIC/RBC/RTMCC/PEC).
Position is More than the Body
Position extends beyond body states. Position reflects who you are.
There was a table regarding human asymmetrical concepts present in this year’s manual that listed characteristics of neutral versus PEC individuals.
It blew me away because it very well matched my personal transition; especially comparing how I am now to when I was a young lad. Check this out.
Live, create, play
Work, formal, rigid
I’ll probably be in jail painting pretty pictures once my wisdom teeth are pulled.
Septums and Chambers
Septums are partitions in our bodies that separate chambers. For example, the diaphragm is a septum between the thoracic and abdominal chambers. These septums stiffen with flexion and loosen with extension.
We want septums to be tight, as septal tightness allows for chambers to expand, shift, and rotate. When a chamber can’t expand, it shall become loose.
If you want a tight septum you must be able to flex. Flexion is what gives one access to shift and rotate.
The normal respiratory cycle alternates between chamber and exoskeletal dominance. Upon inhalation, the exoskeletal system becomes unstable, but chamber pressure increases. When exhalation occurs, exoskeletal stability increases and chamber pressure decreases.
Thinking about this alternation clinically, one who lives in a constant state of inhalation (i.e. extension) will stay upright via chamber pressure. Stability is passive. On the flipside, one who spends more time exhaling (i.e. flexion) must keep upright stability via active elements
The rectum is shaped somewhat like a cone to which a pressure gradient for defecation occurs by gravity and peritoneal cavity shape.
Our natural human asymmetry is necessary to mobilize abdominal contents. Our iliums act as pumps for the rectum, shifting contents back and forth with each step we take.
If we only have access to one phase of gait though…things get shitty.
Create with Your Arms
Hands should be free to reach and create, but when we are in a protective pattern, inability to reference the ground through our legs leads us to find reference elsewhere.
In some individuals, the arms can act as a reference center to hold us upright. This occurs most notably when we lack transverse plane activity. If you see these behaviors, think need for transverse plane:
When one writes, they push the pen into the table as opposed to gliding it across paper.
Hands in pockets (guilty as charged).
When you have people who cannot create with their arms, being able to feel the ground is one of the best things you can do. Ground push-off is what reduces the reference needs of the arms.
It’s Not Illegal for your Right Ab Wall To Engage
One of the biggest mistakes I made was losing a right zone of apposition (ZOA).
A slight right ZOA is necessary when creating right apical expansion. The LAIC/RBC/RTMCC pattern dictates the ribs on the right are closed down. Airflow ought to be used to open up these ribs.
However, if I lose the ZOA on the right by letting my ribs flare and over-externally rotate, the right ribs will stay compressed. All that will be stretched is the right ab wall.
Conclusion: exhale and keep the ribs down and in on both sides. Then upon inhalation, a stretching sensation should be felt in the right intercostals. You won’t take in much air.
It is Illiegal to Overflex
We don’t want turtle humps, as this would be the same as creating excessive kyphosis in standing.
Instead, what we want is appropriate kyphosis via posterior mediastinum expansion. Get a ZOA, keep the ZOA, then inhale.
Mirrors are Cool
We learned some neat tricks you can do with a mirror. The mirror takes away visual reference by disassociating what is being seen from what is being felt.
This strategy is especially useful for people who can’t find and feel muscles on one side but can on another. Check out the video below to see an example.
Public service announcement: When getting your eye exam, ask your optometrist to make sure that you are not overcorrected and that your eyes work together or are balanced. These changes alone will make visual information coming into your brain less threatening for the system.
I came with a new appreciation of the subtalar joint. It’s a triplanar ball and socket-like torque absorber that creates pronation and supination.
This rotational force is not always occurring by the leg muscles however. In the closed chain, the opposite hip swinging forward creates supination in the foot. The effect is like a ratchet (twister is the pelvis, stationary end is the lower extremity).
This rotational component is one possible reason why many orthotic therapies can fail. A foot orthotic must be able to return the entire lower extremity to the center of the frontal plane (i.e. neutral).
Contrary to the haterz, orthotics will not weaken the foot. What they are made to do is change proprioceptive inputs that can have an effect on motor learning. Orthotics can allow one to find and feel muscles they may have not felt before.
It’s a different sensory experience, just like anything you wear is.
Even though PRI likes its orthotics, you may not always need shoes. Sometimes you can gain greater proprioceptive feedback to sense the floor barefoot. It’s going to be person dependent.
The verdict? Wear many different shoes and go shoeless occasionally. Give your dogs variable sensory inputs.
Infamous Ron Quotes
“If you’ve got rhythm you’ve got a diaphragm.”
“You should be moving so sinuses can drain snot.”
“If your gut is moving the bowels in your lungs are moving.”
“You have a center of your body…And I’m going to do this a lot…But it’s not the center of your body.”
“You have to handle the big G in some way.”
“What is this guy nuts? I am nuts.”
“Do something to become alive.”
“Wear different shoes everyday and you’ll probably poop.”
“If you cannot exhale you are probably dead.”
“Is your septum tight? Mine is.”
“If you don’t own yourself you can’t be kind.”
“I gave you these tests just so you would wake up.”
“It’s cool to be twisted.”
“If you suck at twister you can’t uncoil.”
“I like to break the law once in a while.”
“If you are going to do PRI, underbreathe.”
“Pain distorts where you are at.”
“Gosh, all my patients are snakes.”
“Quadratusitis. It preceded ebola.”
“The more references you have the less obese you will be.”
“Curvatures run the show.”
“Really? We’re going to fight to move a joint through a range?”
“Leave the body alone unless you really have to do something.”
“Can you imagine me in black spandex? Or a penguin?”
“I have her in good shoes. She knows I have an attitude.”
“That old bald guy this morning…”
“Oh she’s shaking like a leaf.”
“I’m not afraid to say I don’t know.”
“These type A patients, and I don’t mean Hong Kong Taipei.”
“Neutrality is nothing. You need to be able to work with it.”
“It’s not illegal for your right ab wall to engage.”
“No! I’m sorry, just trying to find the floor on the left side.”
Great James Quotes
“You want to know why? Cuz Ron happens.”
“Extension is not bad if you can manage air and chains.”
“You can train everything but you don’t want to overtrain discord.”
“If you can’t trunk rotate you can’t ZOA incorporate.”
It’s that time of the year that we get to look back and reflect and what posts killed it (and which bombed).
It seems as though my fine fans be on a pain science kick this year, and rightfully so. It’s some of the best stuff on the PT market right now. It’s definitely a topic I hope to write about more in the coming year, and one I will be speaking on at this year’s PRC conference.
But without further ado, here are the top 10 posts of 2014.
Going through the treatment process as a patient has really upped my game in terms of knowing when to integrate with my patients. It has also been a life-changing experience for my health and well-being. Learn how they did it for me.
So much fine tuning occured the second time around. I love how Jen acknowledged the primitive reflex origin of the patterns, as well as fine tuning both lift tests. She’s an excellent instructor (and fun to party with)!
One of the most powerful and humbling courses I have ever been to. Ron goes all out on this course, as it is his baby. What dental integration can do to a system under threat is a concept that I hope is further explored in medicine. We can’t do it alone folks.
This post marked a shift in my thought process and a realization of the possibilities that an integrated health system can accomplish. I have high hopes for our profession, and feel excited that an original post had so many views.
Couple the best manual therapy explanation I have come across and a gentle technique and you get a rock solid course. The only downside is that now Diane has tarnished any other manual therapy course for me, as I can’t rationalize any other explanatory model given.