Course Notes: PRI Cervical Revolution

Where are all the People?

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.

We were on our 1776 shit.
And we were on our 1776 shit.

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.

The puns are endless for this course title.
Reason #62 why not to be facebook friends with me

And even more so, I got to meet a lot of good folks for the first time. It was a real treat.

Viva la Mullin Revolucion!
Viva la Mullin Revolucion! The puns are seriously endless.

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.

This post will not be gone in a day or two.
This post will not be gone in a day or two.

Smudging 901

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.

That's why I never neck with my teeth #doubleentendre
That’s why I never neck with my teeth #doubleentendre

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.

If I find this girl I will marry her.
If I find this girl I will marry her.

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:

Taken from an article by James and Strokon. Check out the original piece: http://www.researchgate.net/publication/6906058_Cranial_strains_and_malocclusion_V._side-bend--part_I
Taken from an article by James and Strokon. Check out the original piece:
http://www.researchgate.net/publication/6906058_Cranial_strains_and_malocclusion_V._side-bend–part_I

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:

Right Torsion 

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:

This is also from a James and Strokon article. Check it out here: http://www.ncbi.nlm.nih.gov/pubmed/16617884
This is also from a James and Strokon article. Seriously, these articles are gold. Check it out here:
http://www.ncbi.nlm.nih.gov/pubmed/16617884

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

Close, though the anterior portion of the splint is built up a bit.
Close, though the anterior portion of the splint is built up a bit in the actual 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

My muse.
My muse.

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.

The EMA

ema

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.

ALF Orthotics

The one and only
The one and only

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.

C’est Fini

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.”
  • “If you have lateral occlusion you poop better.”
I'm sure it's slightly different...
I’m sure it’s slightly different…

Course Notes: The Last Craniocervical Mandibular Restoration Evahhhhh

You’d Think I’d Learn it the First Time Around

You’d think, but CCM is one of the hardest PRI courses to conceptualize.

Story of my life
Story of my life

 It didn’t hurt that my work was hosting the Ron’s last time teaching this course, as next year we will see Cervical Revolution instead.

I took this course last February, and it’s amazing how different the two courses were. We had a room filled with PRI vets, and the Ronimal went into so much more depth this time around.

It was such a great course that I would love to share with you some of the clarified concepts. If you want a course overview, take a look here.

Three generations of...Oh sorry wrong family.
Three generations of…Oh sorry wrong family.

 The TMCC

 The right TMCC pattern consists of the following muscles with the following actions:

Cranial retruders/mandibular protruders

  • Right anterior temporalis
  • Right Masseter
  • Right medial pterygoid

Sphenobasilar flexors

  • Left rectus capitis posteror major
  • Left obliquus capitis

OA flexors that maintain appropriate cervical lordosis

  • Right rectus capitis anterior
  • Right longus capitis
  • Right longus colli

If this chain stays tonically active, then there is better accessory muscle respiratory capacity present. These muscles provide the fixed point needed for an apical breathing pattern.

Great for SCM day at da gym.
Great for SCM day at da gym.

We want the muscles on the other side, the left TMCC, to be active. Their activity will allow alternating reciprocal cranial function to be possible.

We also call this gait.

 Keep Ya Sphenoid Flexed

One cranial goal we have is to achieve sphenobasilar flexion, but what does this mean?

In the RTMCC pattern, the sphenoid is in an extended position. When the sphenoid is extended, the foramen magnum becomes larger and the spinal cord descends. This positioning explains all the chiari malformation jokes that we like at PRI-land.

Hence why I'm starting my Chiari brand clothing line. High heels shall be designed first.
Hence why I’m starting my Chiari brand clothing line. High heels shall be designed first.

This position would also create a forward head posture to create a compensatory airway. Consequently, occlusion may be altered.

The goal is to flex the sphenoid, which closes the foramen magnum and produces appropriate OA extension. This position keeps the brainstem happy.

 Lordosis is Important

 When the SCMs are overactive, especially on the left, a reversed cervical lordosis can occur.

If I see someone who cannot flex his or her neck, I’m not thinking of stretching them into flexion. I’m thinking about restoring cervical lordosis. If no cervical curve is present, then the neck is already at end-range. Stretching farther in this position could create potential pathology.

Lordotic position is achieved by the deep neck flexors listed above and maintained by a twisted levator scapula position under a foundation set by an active lower trap.

Things are just better when kept twisted.
Things are just better when kept twisted.

SCMs

 I learned to appreciate the SCM much more at this course.

In the RTMCC pattern, my OA joint is sidebent to the left. This position occurs due to the left SCM, rectus capitis lateralis, and levator scapula.

When an active left SCM is present, we usually see a corresponding frontal plane positional tug occur at the thorax and pelvis. Left SCM often works with the right quadratus lumborum and right adductor to push the sphenoid, sternum, and sacrum into a right lateralized state.

Pterygoids = Money

 When lateral trusion in protrusion is assessed, we are not really assessing jaw mobility but pterygoid function.

The left lateral pterygoid moves the mandible anterior and to the right no doubt, but it also moves the cranium posterior and to the left. We call this left acetabulofemoral internal rotation aka shifting into your left cranium.

I get the same look when I see lateral trusion restored.
I get the same look when I see lateral trusion restored.

This Really Bites

We discussed a lot about bites this weekend. One bite that would most certainly need dental integration is an anterior open bite. This bite is when the front teeth are unable to contact due to a very high palette.

I believe the technical term is nightmare.
I believe the technical term is nightmare.

This bite type would be the equivalent of rib flares on a PEC individual. When one has an open bite, the mandible retrudes far enough to increase pressure onto the mandibular condyles.

The TMJ essentially begins to act like a molar.

We also got to see an individual with a cross bite, in which the part of the teeth go so far inward that teeth contact occurs at an angle.

Not fun
Not fun

This positioning is very similar to the feet in a left AIC pattern. The right foot is in a supinated position, but the first ray will oftentimes create first ray plantarflexion to touch the ground. A cross bite is a similar phenomenon.

Other Fun Clinical Tips

  • The louder and earlier the click upon TMJ opening the healthier the joint is.
  • Front teeth contact keep temporal bones alive.
  • Back teeth keep head from going forward.

(in)Famous Ron Quotes

  • “I’m not interested in your 45 mm of opening.”
  • “I’ve learned one thing in life. Jaw surgery does not work.”
  • “I call it the quadratus eboli.”
  • “We’re going to talk about sciatica of the head.”
  • “You know, my mother is not so bad after all.”
  • “I want you to take this course because this is life.”
  • “I’ll say feeling cerebrospinal fluid is a bunch of you know what.”
  • “If you’re a mammal you suck. You suck as a mammal.”
  • “If you don’t suck you don’t have a neck.”
  • “Are you a mammal? No Zac you’re weird.”
  • “The IC lateral pterygoid. Oh sorry wrong course.”
  • “You didn’t know getting your IC adductor would help you taste Pepsi better?”
  • “Guess I’ll go to PT school. Maybe I’ll learn something there. NOPE!”
  • “The best thing you can do is invest your retirement dollars on CPAP machines and ambien.”
  • “The system knows everything.”
  • “This patellar, excuse me, temporalis region.”
  • “Buy some Bose headphones and listen to Lady Gaga. Wow! That worked.”
  • “I just walked you through evidence that has been there for years and no one can handle it. Oops.”
  • “Surely. Don’t call me Shirley…Sahrmann.”
  • “I’m not here to recapture someone’s disc…Oh but I am.”
  • “The biggest shim that anyone does is a heel lift and it makes me want to puke.”
  • “If you have one foot that pronates and one that supinates, you’ll need a podentist.”
  • “The number one concussion is the Iphone.”
  • “Salt, pepper, and left lateral pterygoid.”
  • “I want his pube to like his malleolus. Oh I didn’t mean that.”
  • “I’m probably about 1% there.”
  • “Because I’m not the maker.”
He's not Shirley Sahrmann but...
He’s not Shirley Sahrmann but…