I recently did a little spot on IFAST University regarding how I approach, assess, and progress people along the physical activity continuum. Read the little intro below, and if you want to watch the video, click on the picture or the link.
As a bonus, I put together a little PDF outlining how I improve the movement variability side of physical activity. If you sign up for IFAST University, you’ll get access to it.
Without further adieu, here is the post.
The Four Step Process to Address Movement Limitations
I’m in the business of creating change, but — as you know — that stuff is HARD TO DO.
How do you simplify the process?
I like to outline things. When thoughts have a directional flow, it’s easier to keep everything straight. So I have to ask myself questions about each and every situation.
What kind of person is in front of me? And what am I going to do with him or her?
In this post, I’ll outline my process of helping people achieve their health and performance goals. We’ll discuss:The 4 areas where we can start creating change
My main area of focus: physical activity
The 4 steps physical activity
Each step from my physical therapy view
Each step from my performance coach view
My progression for mobility
The 3 active mobility tests I use
Testing for arm motion with lower body tests
Runners who get pain after they run 5 miles
Patients who get back pain after they sit for 4 hours
Athletes who can’t play the whole game without pain
…and a bunch of other short examples to relate this system to your own clients
You’d think, but CCM is one of the hardest PRI courses to conceptualize.
It didn’t hurt that my work was hosting the Ron’s last time teaching this course, as next year we will see Cervical Revolution instead.
I took this course last February, and it’s amazing how different the two courses were. We had a room filled with PRI vets, and the Ronimal went into so much more depth this time around.
It was such a great course that I would love to share with you some of the clarified concepts. If you want a course overview, take a look here.
The right TMCC pattern consists of the following muscles with the following actions:
Cranial retruders/mandibular protruders
Right anterior temporalis
Right medial pterygoid
Left rectus capitis posteror major
Left obliquus capitis
OA flexors that maintain appropriate cervical lordosis
Right rectus capitis anterior
Right longus capitis
Right longus colli
If this chain stays tonically active, then there is better accessory muscle respiratory capacity present. These muscles provide the fixed point needed for an apical breathing pattern.
We want the muscles on the other side, the left TMCC, to be active. Their activity will allow alternating reciprocal cranial function to be possible.
We also call this gait.
Keep Ya Sphenoid Flexed
One cranial goal we have is to achieve sphenobasilar flexion, but what does this mean?
In the RTMCC pattern, the sphenoid is in an extended position. When the sphenoid is extended, the foramen magnum becomes larger and the spinal cord descends. This positioning explains all the chiari malformation jokes that we like at PRI-land.
This position would also create a forward head posture to create a compensatory airway. Consequently, occlusion may be altered.
The goal is to flex the sphenoid, which closes the foramen magnum and produces appropriate OA extension. This position keeps the brainstem happy.
Lordosis is Important
When the SCMs are overactive, especially on the left, a reversed cervical lordosis can occur.
If I see someone who cannot flex his or her neck, I’m not thinking of stretching them into flexion. I’m thinking about restoring cervical lordosis. If no cervical curve is present, then the neck is already at end-range. Stretching farther in this position could create potential pathology.
Lordotic position is achieved by the deep neck flexors listed above and maintained by a twisted levator scapula position under a foundation set by an active lower trap.
I learned to appreciate the SCM much more at this course.
In the RTMCC pattern, my OA joint is sidebent to the left. This position occurs due to the left SCM, rectus capitis lateralis, and levator scapula.
When an active left SCM is present, we usually see a corresponding frontal plane positional tug occur at the thorax and pelvis. Left SCM often works with the right quadratus lumborum and right adductor to push the sphenoid, sternum, and sacrum into a right lateralized state.
Pterygoids = Money
When lateral trusion in protrusion is assessed, we are not really assessing jaw mobility but pterygoid function.
The left lateral pterygoid moves the mandible anterior and to the right no doubt, but it also moves the cranium posterior and to the left. We call this left acetabulofemoral internal rotation aka shifting into your left cranium.
This Really Bites
We discussed a lot about bites this weekend. One bite that would most certainly need dental integration is an anterior open bite. This bite is when the front teeth are unable to contact due to a very high palette.
This bite type would be the equivalent of rib flares on a PEC individual. When one has an open bite, the mandible retrudes far enough to increase pressure onto the mandibular condyles.
The TMJ essentially begins to act like a molar.
We also got to see an individual with a cross bite, in which the part of the teeth go so far inward that teeth contact occurs at an angle.
This positioning is very similar to the feet in a left AIC pattern. The right foot is in a supinated position, but the first ray will oftentimes create first ray plantarflexion to touch the ground. A cross bite is a similar phenomenon.
Other Fun Clinical Tips
The louder and earlier the click upon TMJ opening the healthier the joint is.
Front teeth contact keep temporal bones alive.
Back teeth keep head from going forward.
(in)Famous Ron Quotes
“I’m not interested in your 45 mm of opening.”
“I’ve learned one thing in life. Jaw surgery does not work.”
“I call it the quadratus eboli.”
“We’re going to talk about sciatica of the head.”
“You know, my mother is not so bad after all.”
“I want you to take this course because this is life.”
“I’ll say feeling cerebrospinal fluid is a bunch of you know what.”
“If you’re a mammal you suck. You suck as a mammal.”
“If you don’t suck you don’t have a neck.”
“Are you a mammal? No Zac you’re weird.”
“The IC lateral pterygoid. Oh sorry wrong course.”
“You didn’t know getting your IC adductor would help you taste Pepsi better?”
“Guess I’ll go to PT school. Maybe I’ll learn something there. NOPE!”
“The best thing you can do is invest your retirement dollars on CPAP machines and ambien.”
“The system knows everything.”
“This patellar, excuse me, temporalis region.”
“Buy some Bose headphones and listen to Lady Gaga. Wow! That worked.”
“I just walked you through evidence that has been there for years and no one can handle it. Oops.”
“Surely. Don’t call me Shirley…Sahrmann.”
“I’m not here to recapture someone’s disc…Oh but I am.”
“The biggest shim that anyone does is a heel lift and it makes me want to puke.”
“If you have one foot that pronates and one that supinates, you’ll need a podentist.”
“The number one concussion is the Iphone.”
“Salt, pepper, and left lateral pterygoid.”
“I want his pube to like his malleolus. Oh I didn’t mean that.”
Another retake course is in the books to prep for my PRC testing. This time, it was Myokinematic Restoration with THE Jen Poulin held at Indianapolis Fitness and Sports Training.
This class was my Midwest going away present to myself. IFAST has become a second home to me, and any time I can spend with the folks from there I cherish. Plus ma and pa wouldn’t be too happy with me if I didn’t 🙂
I also had yet to take a course instructed by Jen, so I was very curious to hear her perspective on the PRI science.
I won’t go into the Myokin nitty-gritty like I did here, but what I will do is go into concepts that were cleaned up for me this time around.
Want to know what I learned? Let’s do it!
PRI Patterns = Primitive Reflexes
Ron Hruska just doesn’t make shit up.
Right off the bat Jen stated that the patterns were based off of primitive reflexes that can be elicited in everyone. And for you EBP folks, this is demonstrated here and here.
The left AIC has its origins from the asymmetrical tonic neck reflex, and the PEC from tonic labyrinthine reflex.
and the PEC from the tonic labyrinthine reflex
Jen was the first person to state this claim outright, and to hear it in the basic of basic courses…It made my heart melt.
You Down with Several P’s? Yeah You Know Me.
Another big thing Jen discussed was some very important P-words that if you want to be a PRI Jedi you ought to know:
Posture – Not static posture you uninitiated suckas. This is an action word. We assimilate many different postures every time we move.
Patterns – Based off of primitive reflexes. These traits conduct neurology.
Position – What place is every joint in the body in at a given moment. Can you get out of that position?
Pelvis – The acetabulum. Important for this course.
Performance/pain – What most of us work on.
Parasympathetics – What our end-goal is with PRI.
Poulin – Yeah, she’s awesome.
Take these P’s and add the fact that we are asymmetrical creatures, and you have a complex human being.
Our asymmetry is completely normal. We have a heart on the left and a liver on the right. This alone alters which side of the diaphragm will be larger.
The asymmetries don’t stop there. We need to look at the brain to show what really drives us into these patterns. The left hemisphere has more responsibilities for speech and language than the right side. Since the left hemisphere controls the right side of our body, our right upper extremity becomes dominant in how we communicate, grow, and develop. This preference is normal.
What is abnormal is when we rely solely on this right-sided (not handed) preference to live life. When we over-rely on this lateralization, we lose options to move. We lose mobility. We lose system variability.
The end-game – Live in a balanced state of asymmetry.
That’s a Big Osteophyte. Wonder what He’s Compensating for?
The human system will try its hardest to be able to go left and right; to be able to walk. If my primitive reflexes are not permitting me to do so, then the body will do what it can to compensate.
These patho-compensatory patterns can occur anywhere. Here are some classic myokin examples.
In the left AIC pattern, the spine and sacrum together orient to the right secondary to left diaphragm and psoas hypertonicity. These muscles contralaterally rotate the spine.
If this chain’s tone cannot decrease, the lumbar spine could attempt to bring the individual to the left side by increasing laxity at the iliolumbar ligament. That is the only way the spine could go left from a right lateralized position.
The lumbar spine does the work that the left hip should be able to do.
Another example could be with the left hamstring. In the left AIC pattern, the left hamstring is elongated secondary to an anteriorly tipped and forwardly rotated innominate.
Upon performing a straight leg raise, this hamstring will appear shorter than the right. This finding occurs because the left hamstring hits end-range earlier secondary to position. The left leg would also appear shorter than the right.
To compensate for various reasons, be it increasing stride length or forward bend capacity, the sacrotuberous ligament could become lax and left hamstring tone could decrease. Again, another strategy to create some semblance of left stance.
Patho Anterior Hip
Ah, the most famous of all. In the Left AIC pattern, my pelvis is oriented to the right. This puts my acetabulum on femur (AF) into external rotation on the left and internal rotation on the right. My femur on acetabulum (FA) position would be the exact opposite.
Now, if I have to walk forward and not trip over my feet, I could compensatorily externally rotate my left femur so my foot points forward. When external rotation occurs, the femur glides anteriorly. If I do this for a long enough time, my iliofemoral and pubofemoral ligaments could become overstretched, thus creating pathology so hip extension can occur.
PEC. The Ferrari of Compensators
We are all born left AICs, but the PEC. That’s some next level stuff.
What the PEC individual does is use the right side of the lower back to attempt movement into the left side in the transverse plane. Creating excessive extension keeps one upright.
What limitations occur on the left side, now occur on the right.
Still, it is important to note that many Left AIC techniques will work on PEC individuals because under every PEC is a left AIC.
Muscle Roles – In terms of function
In the left AIC pattern, many secondary movers have to become prime movers secondary to position. In other words, would-be supporting characters such as the TFL try to steal the show.
And we ain’t havin’ that.
The goal then, is to inhibit these chains so prime movers become prime movers and secondary movers know their role.
A couple muscle functions and thoughts that were cleaned up for me:
Vastus Lateralis – Holds us up when we stand on the left leg in the left AIC, attempting to protect our left anterior hip.
Adductor Magnus (adductor portion) – Externally rotates the hip in extension. We want this adductor early in the swing phase of gait.
Obturator internus – Control AF positioning from the other side. They statically hold the pelvis in place so the femurs can do work. Positionally, the left obturator is actively insufficient due to excessive shortening, whereas the right obturator is passively insufficient due to excessive lengthening.
Lift Tests (Gasp)
Yes. We were fortunate to see the ADDuction and ABDuction lift test at this course. I figured it was about time to show how these work…through film.
First up, we have the Hruska Adduction lift test. This test looks at AF strength and simulates stance phase. Most importantly, the video features Young Matt!
(I say he scores a 5, but after review I’d give him a 4…I got excited).
Here is how it’s scored.
0 = Can’t get into position or raise lower ankle off of table.
1 = Can raise lower ankle to upper knee.
2 = Can raise lower knee and ankle (need to feel IC adductor and glute med on the bottom leg)
3 = Can slightly lift bottom hip off table while maintaining position.
4 = Can raise hip completely off table.
5 = Can raise hip above the level of the patient’s shoulder.
And here is what you go after based on what someone scores.
0 = reposition and stretch obturator.
1 = Need glute max and posterior capsule to be able to do.
2 = Need IC adductor and glute med.
3 = Get the glute max to keep AF ER stability and work on left trunk rotation/right arm reaching.
4 = Emphasize right trunk rotation/left arm reaching with alternating activity.
5 = Take over the world.
The Hruska ABduction lift test was finally demoed this class. It is a higher level beast; reserved for those who can score 3/5 B on the Adduction lift test. This test looks more at the swing phase of gait, and is a tough one to do.
(After careful review, my top leg should’ve kept more IR during part 4&5).
Here is how it’s scored
0 = Can’t get into position.
1 = Can push bottom hip into surface.
2 = Can push bottom foot into wall and lift bottom knee.
3 = Can perform internal rotation on the top leg without moving the top pelvis forward.
4 = Can raise the top leg completely off the wall and hold without using lateral trunk muscle.
5 = Can extend the top leg without back extension, knee flexion, or hip external rotation.
And here is where you go based on the score.
0 = Pelvic repositioning if needed; activities that combine adduction on one leg with abduction on the other. Rotation on both. Think lower level combined activities though.
1 = Need abdominal activity to perform. Think internal oblique/transversus abdominis.
2 = Need IC adductor and glute med to perform.
3 = Need posterior glute med on the top leg and anterior glute med on the bottom leg.
4 = Need to combine top leg abduction with bottom leg adduction. This activity best simulates midstance.
5 = Need top leg glute max while on a stabilized (AF IR) bottom leg.
Clinical Pearls for the Girls (and Boys)
Gait tweak – Cue someone to take bigger steps with their right leg.
PRI is very similar to muscle energy techniques (MET). The only difference? Respiration!
When a repositioning technique occurs, you change the acetabulum, not the femur.
Perform the standing reach test (toe touch) in an open stance and to either side. This test can help demonstrate if someone is patho or not asymmetrically.
To cue ankle eversion, have someone push his or her medial malleolus into a small ball.
If someone is getting TFL cramping during an exercise, they likely need more posterior capsule inhibition.
PECs have high arches due to the compensatory tibia external rotating.
Wise Words from THE Jen Poulin
“Neutral is getting to the start of rehab”
“If you hold your breath are going to be parasympathetic? Heck to the no!”
“He liked all my tweets.”
“Get people in the land of drool. Parasympathetics.”
“I’m going to treat your back from the front.”
“What are we going to do this weekend? We’re going to solve mysteries and get Scooby Snacks.”
“If you have a headache patient please touch her head. But if she has no butt, you will not fix her headaches.”
“The patella is a sesamoid bone. It’s going to go where it’s told. It doesn’t have a mind of it’s own.”
“Don’t tape a patella when you’re tonified.”
“I didn’t stretch her. I shut her down.”
“We’re all neuro patients.”
“Neutrality is a place in between.”
“Get ‘em shut down. Get ‘em purple.”
“When it’s a crown and jewel to pee on the floor it’s not good.”
“You don’t have to do PRI activities for the rest of your life, but you better cuddle your dog at the end of your life and be parasympathetic.”
“Under every PEC pattern is a left AIC pattern. Tweet that!”
“I can guarantee you and you don’t want to bet against me.”
“The diaphragm is the core of your core. If you’re not using it, you’re missing the boat.”
“Always always always downgrade your patient.”
“What level is she? A big, fat, skinny 0.”
“He doesn’t count. He’s done PRI. You’re not pure.”
“All the brain knows is patterns.” ~Ron Hruska
“Is this your water? I’ll take that risk.”
“Liz [Messina], can you use your mouth? I know it works well.”
“Be Bob Ross. Be creative.”
“It’s fraudulent hip extension. You’re a fake. You’re a fraud.”
“Your patients are gonna want it.”
“Pain says stop. Stop being twisted.”
“Handedness isn’t determined until you’re upright.”
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.
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.
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.
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.
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.
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.
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.
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 . 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.”
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:
What courses should I look at?
Any advice for a new grad?
Seriously, Bane. What’s the deal?
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.
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:
Symptoms after prolonged or unusual postures.
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.
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.
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.
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.
Breathing will become faster and shallower. Take a look at the diaphragm. Which side is larger?
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.
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…
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.
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.
Just recently attended another excellent PRI course taught by Lori Thomsen and new instructor Jesse Ham called Pelvis Restoration.
The weekend was filled with great discussion about inlets, outlets, shoes, and many other pearls that helped solidify my PRI understanding.
So without further ado, let’s summarize. If this is your first reading on a PRI course, it may be beneficial to review my post on Myokinematic Restoration.
Jesse started off the class discussing some PRI basic philosophical tenets.
In PRI, we talk a great deal about position, which will be defined as a stance or posture at one point in time. Or as Jesse defined it, a position one can maintain for an extended period of time without pain.
With this operational definition, our goal as a PRI clinician or trainer is to organize activities in the following order:
Reposition – inhibit muscle chains.
Retrain – Facilitate muscle chains
Restore – Create reciprocal alternating activity (using all muscle chains when it is desired).
Reciprocal activity is defined as going from one end-range to another (extension to flexion) and alternating activity is switching from one side of the body to another (right to left stance). When we alternate, the joint on one side of the body ought to do the exact opposite at the other side.
With the above treatment hierarchy, we are working on allowing positional freedom within the person being treated. We call this movement in multiple planes.
Now the Pelvis
This part is where things can get confusing, as we begin talking about pelvic inlets and outlets. The best way to learn about pelvic positioning is to visualize it. So watch the videos below to learn more.
Now our goal for treatment is as stated above: alternating reciprocal function. So when we are in right stance during gait, our right pelvic and thoracic diaphragms should ascend. During left stance, ascension ought to occur on the left thoracic and pelvic diaphragms. In an individual who cannot get out of right stance, these left diaphragms stay descended.
This positioning leads to certain muscles being more facilitated (on), and others being inhibited (off).
In order to get into left stance, we must inhibit and facilitate the following:
Left anterior inlet
Right posterior inlet
Left posterior outlet
Right anterior outlet
Right anterior inlet via the right rectus femoris and Sartorius
Left posterior inlet via the left iliacus through the left anterior gluteus medius
Right posterior outlet via the right coccygeus and piriformis through the right glute max
Left anterior outlet via the left puborectalis, pubococcygeus, obturator internus, and iliococcygeus through the left ischiocondylar adductor.
Those Darn PECs
This class is the one that discusses in-depth the posterior exterior chain (PEC) pattern; the one everyone wants to know about.
The PEC consists of the lats, QL, posterior intercostals, serratus posterior, and iliocostalis lumborum. When this chain is turned on, we see the following occur
Flatter thoracic spine
Increased lumbar lordosis
The chain acting as an accessory respiratory muscle.
Restricted positioning into Right AIC pattern.
Unilateral hypertonicity restricting contralateral trunk rotation and sidebend.
Basically, this muscle chain throws you into an anteriorly weight-shifted position, thus facilitating increased extensor tone.
Lori stated that 80-90% of the people we will see will have a variation of this pattern. So why is it talked about so little? The answer to that is because under every PEC there is a left AIC pattern. The former is merely a greater protective positioning response.
In this pattern the pelvis looks a little differently than the left AIC pattern:
So with the above positioning and concomitant muscle facilitation/inhibition, we must use different muscle groups to decrease the extensor tone. This strategy will help achieve the reciprocal functioning. In this case, our friends become the internal obliques, transversus abdominis, and proximal adductors via utilizing a posterior pelvic tilt.
The aforementioned strategy is utilized regardless of if your patient/client is non-pathological or pathological. The only difference is that it may take more time to treat one who has a patho pattern.
This is a Test
There were a couple new tests that we learned here to assess the pelvis, which are similar to your typical orthopedic tests.
Adduction drop (ADT): Basically the Ober’s test; looks at pelvis position
Standing reach test (SRT): toe touch
Pelvic Ascension drop test (PADT): Active Ober’s test; looks at the ability of the pelvic outlet to abduct.
Passive abduction raise test (PART): passive hip abduction ROM; tests if the outlet can adduct.
functional squat test (FST): getting into a deep squat; similar to if you were going to the bathroom.
Hruska adduction lift test (HALT).
Posterior mediastinum expansion test (PMET): Breathe in posterior thorax to assess thoracic flexion.
Apical Expanstion test (AET): Fill apical chest wall unilaterally to assess trunk rotation.
The above tests are used to determine position and guide treatment. For example, a left AIC would present in the following manner:
+ left ADT
SRT > 0”
+ Left PADT
+ Right PART
R HALT <3/5
The positive testing above would indicate the pelvis is anteriorly tipped and forwardly rotated, with an adducted left outlet (PADT) and an abducted right outlet (PART).
A PEC would see the above bilaterally, except PART would be negative on both sides.
What was most interesting for me regarding these tests is determining if one is considered pathological or not. It turns out, one can be considered pathological for a multitude of reasons; not just negative Thomas Tests.
For example, take our PEC person above. Say instead of having a negative PART bilaterally, they have a positive PART bilaterally. Since this test result would be atypical, we would consider this patient patho; even if his or her Thomas test is negative. I sadly found out the hard way 🙁
Other ways one could be patho in the PEC route would be if one could achieve a full squat or touch their toes. You only need one thing out of the ordinary to be pathological.
The deciding factor which determines utilizing a pelvis restoration treatment algorithm is the PADT. If after you get someone’s adduction drop test to go negative, and the PADT remains positive, you likely have a pelvic restoration patient/client. Again, this rationale is due to the pelvic outlet remaining in an adducted position, thus not allowing the femur to adduct.
One other clinical possibility that I have found is based off of your HALT scores. Generally (not always), if your patient has low bilateral lift scores (0-1/5 B), you more likely have a pelvis restoration patient. Use your test clusters to guide which route you go.
When the patient is positioned as a Left AIC, we perform activity in the following order:
1st Goal: Turn on right anterior pelvic inlet
How: right rectus femoris and Sartorius
When: + L PADT, +R PART, R HALT 0-1/5
2nd Goal: Turn on left anterior pelvic outlet
How: The left adductors (left iliococcygeus & left obturator)
When: + L PADT, +R PART, R HALT 1+/5 (can start to pick up leg)
When: + L PADT, + or – R PART, R HALT 2-/5 (can’t feel gluteus medius during lift)
4th Goal: Turn on right posterior pelvic outlet
How: Right glute max, coccygeus, and piriformis
When: – L PADT, + R PART, R HALT 2 or 3/5
Lori also discussed an inhibition program, which is something I probably have not focused on as much in the past with my patients. Oftentimes if you are not getting the desired changes with the above algorithm, you may have to decrease tone in particular areas to achieve your goal. Here are some possible ways to use inhibition to enhance your program.
Goal: Turn off left anterior inlet
How: Turn on left internal obliques and transversus abdominis
When: + L PADT, + R apical expansion, + L posterior mediastinum
Vid – late left stance with right arm reach
Goal: Turn off right anterior outlet
How: Shut off right adductor via left adductor and glute med
When: – L PADT, + L PART
Goal: Turn off right posterior inlet
How: Get distal fibers of right iliacus via abduction
When: – L PADT, + L PART, decreased right external rotation (<45 degrees)
Goal: Turn off left posterior outlet
How: Via the left adductor
When: + L PADT, + L PART
So now that you have facilitated or inhibited what you need, you likely have the HALT score of 3/5. This value is when one could be “cleared” to stand. So from here, we work towards alternating reciprocal activity aka gait. We progress in the following order:
Left single leg control
Right single leg control
Seated pelvic ascension control
Reciprocal alternating activity
PEC patients (+ Bilateral ADT) go along the exact same route as the left AIC patient, with a couple steps beforehand.
The initial goal is to work on getting one reciprocal, so breathing becomes top priority. Oftentimes with these people you may just work on the basic breathing technique of keeping the ribs down and in, holding position, and breathing.
Once they have adequate technique, we try to inhibit the left anterior inlet and left posterior outlet via abdominals
A patho PEC goes under the exact same protocol, only likely taking more time. Quadruped or standing will be easier positions as the abdominals will not have to work as hard to tilt the pelvis against gravity
That Last 20%
So say you have gotten someone neutral and they feel 80% better. What’s that last 20%? There may be several avenues to consider:
Respiratory activities (Coordinating extremities with breathing during PRI activities).
Perform kegels while in left AF IR.
Focus on seated activity.
Can’t get to or maintain neutral
You may run into the case where your tests either won’t go negative or stay negative. We have a hierarchy for that as well:
Correct breathing technique.
Inhibition, inhibition, inhibition.
Make sure patient is feeling desired muscles working.
If the above do not seem to work, then likely interdisciplinary integration may be needed. More on that to come with future posts.
Shoes and Such
Lori is the resident PRI shoe expert, so we discussed what qualities are needed in shoes. Here are the big things you want to look for:
A stable and narrow heel counter
Minimal lateral heel give.
Flexible lateral toe box
However, if you are able to stay neutral in the shoes you wear, then the above may not be necessary. In certain instances they could be counterproductive. Because these shoes typically have a more elevated heel, if one has other areas driving one into extension (e.g. vision), these shoes could drive extensor tone further.
The Hruska clinic has a recommended shoe list which you may access here.
“Society is counterclockwise.”
“Most furniture is designed to fit people who are 5’8.”
“Monovision is killing us.”
“Get people off their IPads and IPhones. Go off and do life.”
“There is nothing wrong with half the gait cycle.”
“Left AICs are leg whippers with running.”
“A balloon is like weightlifting for the ribcage.”
“Mouth breathing promotes extension.”
“Neutrality is baby bear, not too flexed, not too extended.”
“Treat by patterns, not by symptoms.”
“80% of people will get better on basic PRI.”
On the Pelvis
“Inlet position gives outlet power.”
“Knee position reflects inlet position.” E.g. knee forward is akin to flexed inlet.
“The mediastinum reflects the outlet.”
“PECs will get into left stance by hyperextending the back or the knee.”
“PECs are pullers versus pushers [in gait].”
“A PEC walks like a penguin.”
“Anterior Necks love to be abs for PECs.”
“High toilets put you into PEC by descending the pelvic floor.”
“PECs use necks to create thoracic flexion.”
“When PECs stand, have them pick a leg.”
“Drop the ribs to get ZOA; don’t round the shoulders.”
“If you can’t get a good breath in with rounding, check the posterior mediastinum.”
“When blowing up balloons, don’t get chipmunk cheeks.”
“If you want to turn off a right QL, please turn on a left ab.”
“Passive breath in, use everything with the exhale.”
“If on a computer, look 20 feet away for 20 seconds every 20 minutes.”
“Balloons, balls, and bands help inhibit.”
“She’s shaking and I’m getting a little sadistically excited. I’m like that.”
“You know I’m not usually the funny one so I appreciate it when you laugh.”
“Is that kinda fun? I think it is, I don’t know about you guys.”
Jae: “You can’t always get both adduction drops to go.” Lori: “Well I can.”
“I don’t know everything. I know, that’s shocking.”
It seems like I took this course forever ago, but reviewing this post reminded me why I love the NOI group so much. I feel as though their message is one you cannot get enough of.
As for GMI itself, I find that it is great for people who most every movement hurts, as well as an educational piece. From a PRI perspective, it is also useful. I have had patients imagine contracting their glute max and go neutral. Crazy stuff.
Such a great class. Here we see updates to the science behind “The Sensitive Nervous System”, as well as some neat tweaks to our neurodynamic testing. My favorite pieces were on the immune system and genetics.
This chapter is dedicated to showing the connection between the body and consciousness; how our psyche is influenced by breathing and vice versa. This chapter was easily my favorite out of the entire book.
Optimal breathing involves moderate abdominal expansion, some intercostal involvement, and minimal involvement of accessory muscles. Conversely, chest breathing is dominated by accessory muscle use. These two breathing styles are merely end points on a continuum rather than discrete categories.
In terms of which strategy is used, chest breathing is often the preferred route for consciously mediated intentional breathing; whereas abdominal breathing is the main route for relaxed, automatic breathing.
One reason you would want to override automatic breathing is to prepare for sudden action. At the onset of exercise, ventilation immediately jumps. This change occurs via three phases, with the first phase occurring independent of exercise load. This phase is a conscious exercise preparatory action. The other increases occur as exercise demands increase.
When we are in an emergency situation, these breathing phases change. Prior to the initial pre-action deep breath comes a breath holding phase, which helps increase sensory organ stability.
These preparatory breathing changes are great for imminent danger or action, but problematic when threats are non-physical and in the future. While these situations do not require immediate breathing changes, the body still prepares for the threat when it is on the mind.
It is in these emergency situations we see the advantages of chest breathing, which include the following:
Prepare for action
Protect from physical confrontation; as abdominal muscle tension decreases abdominal breathing.
Increases in cardiac output and heart rate.
Can get more air via mouth breathing (voluntary), which is often associated with chest breathing.
Classical conditioning can play a huge role in how we breathe. Many different stimuli can lead to certain responses being elicited, and this effect occurs much more quickly when fear is involved. This is why something such as fear associated with a panic attack can lead to such quick physiological changes. We want these changes in fearful situations, as the last thing you want to be doing when a threat is imminent is thinking about how you should breathe. The brain best prepares you unconsciously based on past experience.
Learned fear is much attributed to the limbic system. The hippocampus and amygdala have slightly different functions regarding memory. The hippocampus deals more with conscious memories, whereas the amygdala houses our protective unconscious ones. The amygdala’s functionality allows us to respond quickly to threats without conscious deliberation.
The amygdala is a very useful brain structure when our lives are threatened. The problem is that its alarm system cannot tell the difference between actual and potential threats. So that thought about planning your wedding 4 months from now that stresses you out may lead to protective responses kicking in via the amygdala; just to ensure your survival. It is for this reason that the breathing changes that occur when we are in danger may perpetuate and become one’s norm.
It seems the more and more that I read the more and more and read the more and more addicted I become to appreciating the nervous system and all its glory. To satisfy this addiction, I took Mobilisation of the Nervous System with my good friend Bob Johnson of the NOI Group.
This was the second time I have taken this course in a year’s span and got so much more value this time around. I think the reason for this enrichment has been the fact that I have taken many of their courses prior and that I prepared by reading all the NOI Group’s books. A course is meant to clarify and expand on what you have already read. So if you are not reading the coursework prior, you are not maximizing your learning experience.
What made this course so much more meaningful was being surrounded by a group of like-minded and intelligent individuals. As many of you know, I learned much of my training through Bill Hartman. Myself, Bill, the brilliant Eric Oetter and Matt Nickerson, my good friend Scott, and my current intern Stephanie, all attended. When you surround yourself with folks smarter than you, the course understanding becomes much greater. This course was so much more with the above individuals, so thank you. Try to attend courses with like-minded folks. Here are the highlights of what I learned. If you would like a more in-depth explanation of these concepts, check out my blogs on “The Sensitive Nervous System.”
Neurodynamics, Clinical Reasoning, and Neuroscience
When discussing clinical reasoning and neuroscience, we have to discuss processing. The pain processes are what we end up treating in rehabilitation, so we have to know where our patient’s problem occurs along the process:
Input – Issues in the tissues; typical therapeutic approaches.
Processessing – How the brain interprets inputs.
Output – The experiences and emotions we feel.
Processes, as opposed to structures, are what we really treat. We can define processes as changes in the physiology. These changes can include degeneration, ischemia, stiffness, inflammation, etc.
In terms of inputs, the two types of input processes that may lead to a pain mechanism include nociception (the firing of A delta and C fibers from tissues) and peripheral neuropathic (involving the neural tissues outside the dorsal horn). The above mechanisms have predictable stimulation responses.
Understand that all injuries to structures are the same, but the context and environment affect processing and output. We have all experienced this phenomenon. A paper cut can hurt like hell, but a cut from a branch while hiking in the forest may not even be noticed. Context makes all the difference.
The pain mechanism related to processing occurs in the central nervous system. With processing problems, the stimulation-response relationship is unpredictable. Thoughts, feelings, past experiences, knowledge, and other states can affect responses here. These components are designed to help us survive our environment.
Lastly, there are several outputs related to pain mechanisms. These outputs involve all our body systems, with the central nervous system acting as the driver.
All these pain mechanisms–input, processing, and output—are involved in some way during a pain state or sensory alteration. One can be more dominant than the others, but all areas are active. It is similar to energy systems. The aerobic, lactic, and alactic energy systems are always active with one often as the primary driver. So too are the involved pain mechanisms.
Often, genetics is the biggest contributing factor to chronic pain development. It is strongly hereditary, like having blue eyes. Here were some values given in the course as to what percentage of pain is genetic:
50% of migraines.
55% of menstrual pain.
35-68% of lower back or neck pain.
50% of shoulder and elbow pain.
40% of pain with carpal tunnel syndrome.
The Nervous System is a Continuum
The nervous system is one of three continuous systems, the other being vascular and fascial. If you move the nervous system at any one place, the entire system moves. It is like moving a tree branch and creating motion throughout the whole tree. Continuum concepts cannot be enhanced by tissue dominant approaches.
There are four ways in which the nervous system is continuous:
Discussing nerves often puts people at unease. However, this feeling should not be the case. Nerves are like any other tissue. Therefore, they live under the same rules as all other tissues. They can bend, twist, and slide transversely. Nerves can also take on increased pressure by loading.
This interconnected quality often confounds traditional segmental-based testing such as myotomes and dermatomes. The nervous system ought to be thought of instead as a continuous piece with multiple reference points.
Moreover, everyone has a different nervous system. Therefore, each person may require a different sequence when performing neurodynamic tests.
Ion channels are the molecular targets for manual therapy. These channels go where no myelin is present:
Dorsal root ganglion
Nodes of Ranvier
There are six points to describe these ion channels:
1) They are proteins with holes in the middle.
2) They have holes that open or close.
3) Some stay open for longer.
4) There are different kinds of channels.
5) They have a half-life of 2-7 days.
6) They represent needs and perceived needs.
I will not go over all the neurodynamic tests in this post, but there were some different variations that I liked in this course compared to what I was doing. The biggest thing when performing these tests is to have a consistent starting position every time. And if you are doing a straight leg raise, pay attention to potential responses on the contralateral leg.
Here is a radial neurodynamic test…proximal to distal style.
The biggest thing that I got out of the nociception section involved inflammation. First off there are two types of inflammation:
1) Non-neurogenic – occurs with tissue damage; creating bleeding and fluid buildup. NSAIDs work well on non-neurogenic inflammation.
2) Neurogenic – Created via C-fibers, which is driven by changes in peripheral tissues and threat perception. It can occur even if the nervous system was not fully involved in the injury. Pregabalin,Gabapentin, Cymbalta, and other similar drugs work well with these.
Peripheral Neuropathic Highlights
Injury to peripheral nerves involves blood flow, axoplasmic flow, and development of abnormal impulse generating sites (AIGS) along the nerve. There are also three different issues that can occur in the nervous system:
Physiologic conduction blocks – local circulatory changes
Neuropraxia – Local conduction block where axon is okay and conduction returns in weeks to months.
Axonotmesis – Axon continuity loss with intact endoneurial tubes; Wallerian degeneration occurs.
Central Sensitivity Highlights
It is important to understand with central sensitization is that it occurs with all injuries. The difference between those with and without chronic pain is that the sensitivity stays turned on.
The CNS utilizes opiate components to combat nociception. There are three major endogenous opioids produced in the central nervous system to create an anti-nociceptive response:
Endorphins – produced in the periaqueductal gray matter
Enkephalins – Produced in the Nucleus raphe magnus
Dynorphins – produced in the spinal cord.
There are also exogenous opioids, which include epidurals, TENS units, and counter-irritants. However, if the endogenous piece is not present first, these opioids will not work.
Arguably the most important part of the entire course was Bob’s talk on the immune system and glia. Research is starting to show that glia runs the central nervous system. They are the gate and clean up synapses. Inflammation can activate glial activity via the vagus nerve, and when glia activates are opioid systems become much less effective. Nitric oxide is also released, which can sensitize receptive fields in the periphery.
A Side Note
One area that I struggle with in pain education is patients who either dislike pain or have huge functional changes but still have some pain. Bob suggested with these folks that this problem deals with the patient’s beliefs. The best thing to do is to talk around the beliefs or find methods to get them to detach from the pain. This could involve meditation or other similar outlets.
Great Bob Johnson Quotes
“Pain is your brain loving you too much!”
“Spreading pain is connecting the dots in the nervous system.”
“We are good at gathering data, but we are not good at determining what is relevant. Gather the data and make it tell a story.”
“Ask the patient what they think the issue is.”
“Showing the patient how they are better is a central component.”
“All we do is move people.”
“We want pain freedom, not pain control.”
“If I save a patient a day, I did something good.”
“When you treat the container, you treat the nervous system.”
“Sensitivity is plastic.”
“A 30-35 degree SLR is needed for normal gait.”
“We rarely see true nerve root compression.”
“Sliders are like grade I & II mobilizations.”
“Nerves love space, movement, and bloodflow.”
“Cardiovascular health has everything to do with nervous system health.”
“The better cardiovascular fitness, the less pain people with chronic pain have.”
“Most patients have a spinal component to a peripheral piece.”
“Beliefs are a big deal.”
“A biochemical memory is left in the tissues…An immune marker.”
“Movement is Wolff’s law for the nervous system.”
“The pattern of central sensitivity is no pattern.”
When we first started working with the nervous system, oftentimes we called pathological processes adverse neural tension. The problem with this name was that it left out nervous system physiology; it was mere mechanical concepts. Hence, we call the movement and physiology of the nervous system neurodynamics.
General neurodynamics account for whole body fundamental mechanisms, regardless of region. Specific neurodynamics, on the other hand, applies to particular body regions to account for local anatomical and biomechanical idiosyncrasies.
There are three parts to the neurodynamic structure:
1) The mechanical interface
2) The neural structures
3) The innervated tissues
The mechanical interface is that which is near the nervous system. It consists of materials such as tendon, muscle, bone, intervertebral discs, ligaments, fascia, and blood vessels.
The neural structures are those which make up the nervous system. These structures include the connective tissues that forms the meninges (pia, arachnoid, and dura mater) and peripheral nervous system (mesoneurium, epineurium, epineurium, and endoneurium).
The nervous system has mechanical functions of tension, movement, and compression. It also has physiological functions to include intraneural blood flow, impulse conduction, axonal transport, inflammation, and mechanosensitivity.
The innervated tissues are simply any tissues that are innervated by the nervous system. They provide causal mechanisms for patient complaints, and are able to create nerve motion. When we have neural problems, sometimes the best treatment is to these structures. You must treat everything affected.
The nervous system is capable of performing many mechanical activities:
Tension – Typically occur at joint areas; the perineurium guards against excessive tension.
Sliding – Neural structure movement relevant to adjacent tissue. Is able to dissipate tension.
Longitudinal sliding – Sliding down the tension gradient to allow for tissue borrowing at elongated areas.
Transverse sliding – Dissipates tension by enabling nerves to take the shortest course between two points when tension is applied. It is also helpful when nerves are subject to sideways pressure by interfaces.
Compression – The nervous system alters its dimensions and position when forces from the mechanical interface are transmitted to the nervous system. The epineurium protects from excessive compression.
Nerve movement depends on the nerve’s location relative to the joint. If the nerve is on the convex joint side, elongating forces will occur. Conversely, if the nerve is on the concave side, shortening forces will occur.
Despite these forces, nerves may not always move accordingly. The reason for this paradox of sorts is because neural tissue is borrowed from each end of the nerve tract. Therefore, nerves will displace towards the joints; with the end effect being little movement at the midpoint. This phenomenon is called “convergence.”
Interfaces have two actions relative to the nervous system:
Closing – Reduce distance between the neural tissues and movement complex; creating pressure on the nervous system.
Opening – Increases distance between neural tissue and interface; reducing nervous system pressure.
These actions can have profound impacts on the nervous system. Take closing for example. It is possible that if a muscle has increased tone or guarding, pressure could increase along a peripheral nerve and create symptoms.
The Nervous System is a Continuum
Any one movement of the nervous system can affect movement at areas further away. Two interesting examples of this occurrence are at the cervical spine and lower back. It has been shown that sagittal neck movement change position and tension in lumbar spinal cord and nerve roots. The other example includes the eyes. When a bilateral straight leg raise is performed, the eyes move inward.
In order to implicate the extent of the nervous system’s involvement requires structural differentiation. The way this action can be achieved is by moving neural structures in the questioned area without moving the musculoskeletal tissues in the same region. An example of this would be symptoms evoked at the wrist with wrist extension that can be altered by changing head position. Because the nervous system is one piece, a pathological process at one area affects the system in its entirety.
Response to Movement
The nervous system moves in a specific order when motion at a joint occurs. First, slack is taken up in early range. Next, sliding occurs in the mid-range, finally, tension builds at end-range.
Slack –> Slide –> Tension
These principles can thus be applied to treatment. A slider involves large movements through the mid-range, whereas a tensioner is performed more at end-range. If someone is incredibly irritable, simply taking up slack in the nervous system can be performed.
Nerves love three things
3) Blood flow
Interestingly enough, peripheral nerve blood flow is regulated by nerves. The major players here are nociceptors and sympathetic fibers. The nociceptive C fibers create vasodilation, which is counterbalanced by the sympathetic nerve’s vascoconstrictive qualities.
Here we shall discuss neurogenic inflammation. This type is when inflammation is produced efferently by the peripheral nervous system; predominately in the c fibers, dorsal root ganglion, and nerve root.
We can test neurogenic inflammation by stimulating the skin. If there are changes in vasodilation capabilities from one side to the other, a potential neurogenic problem may be present. Reduced vasodilation may implicate denervation, whereas increased vasodilation may mean a hypersensitive neural tract.
Neurodynamic sequencing relies on nervous system non-uniformity. There are several big points regarding sequencing movements.
Movement sequence affects symptom distribution with neurodynamic testing.
More likely to create symptoms in area moved first.
Greater nerve strain occurs at the site that is moved first.
Sliding direction depends on movement order.
These principles occur anywhere in the nervous system.
Oftentimes when performing neurodynamic testing, resistance will be encountered. This resistance is usually muscle guarding, but it is entirely possible that nerves provide some of this resistance. Regardless of what is causing resistance, this protective mechanism must be respected. This reason is why usually neurodynamic tests are held for only a few seconds and applied slowly.
Applying these concepts to treatment, we can grade how challenging a movement is to the nervous system. This is where we define sliders and tensioners. Sliders are created to produce a sliding movement to improve pain states and nerve excursion. Tensioners, on the other hand, help improve nerve viscoelasticity and physiology.
Another sequencing aspect that can be beneficial is interface testing within neurodynamics. An example of this test would be having a person contract a muscle during a neurodynamic test. This specificity can be useful in detecting hard-to-find processes.
We change the name of this testing to neurodynamics because it accounts for changes in nerve sliding, cross-sectional area and shape, transverse position, axial rotation, viscoelasticity, intraneural blood flow, and mechanosensivity. Calling these tests tension tests only account for one aspect of the nervous system’s capabilities. So to for neural provocation tests, as we are not always trying to provoke symptoms.