Back in April I had the pleasure of finally attending PRI’s annual symposium, and what an excellent learning experience.
The theme this year was working with high-powered, extension-driven individuals.
The amount of interdisciplinary overlap in each presentation made for a seamless symposium. Common themes included the brain, stress response, HRV, resilience, and drive. These are things altered in individuals who are highly successful, but may come at a cost to body systems.
If you work with business owners, CEOs, high-level athletes and coaches, high level positions, straight-A students, special forces, and supermoms, this symposium was for you.
And let’s face it; we are both in this category!
There were so many pearls in each presentation that I wish I could write, but let’s view the course a-ha’s.
The Wise Words of Ron
Ron Hruska gave four excellent talks at this symposium regarding high performers and occlusion. Let’s dive into the master’s mind.
People, PRI does not think extension is bad. Extension is a gift that drives us to excel. Individuals who have high self-efficacy must often “over-extend” themselves. This drive often requires system extension.
Extension is a consequence, and probably a necessary adaptation, of success.
If this drive must be reduced to increase function and/or alter symptoms in these individuals, we have to turn down the volume knob.
How can we power down these individuals?
Limit alternate choices – These folks take a wide view of a task
Set boundaries – These folks attribute failure to external factors
Making initial tasks successful – So these folks don’t give up at early failures
Objectively measure improvement – This helps motivate people to continue
Establish rhythmic activity that reflects specific set goals – the higher the goals the more likely the positive change.
A Tale of Two Forward Heads
We discussed a lot of attaining neutrality at the OA joint. What does that entail?
A: Both occipital condyles centered in the atlas fossa with unrestricted lateral flexion.
What is needed to have that?
55-60 degrees of cervical extension.
Equal bilateral first rib rotation position.
Centric occlusion with the anterior teeth guiding protrusive movement and canines guiding lateral movement.
Normal maxillary and mandibular teeth contact.
Ability to nasal breathe.
Alternating pelvic capability.
Normal hearing bilaterally.
Lose any one of these and a forward head posture may occur.
The two types of FHP we see include one with the atlas migrating forward with increased cervical flexion and occipital protraction.
And one in which the atlas migrates backward on the occiput in which excessive upper cervical flexion coupled with lower cervical/upper thoracic hyperextension.
With the former’s case, these individuals have a harder time feeling posterior teeth; a loss of frontal plane. When one loses frontal plane, the individual must attempt to increase anterior guidance via extension. Strategies used to do this include tongue thrusting, bruxism, fingernail biting, mouth breathing, clenching, etc. These strategies are protective in nature as they limit potential stress at the TMJ and OA.
Most of the latter include your bilaterally extended individuals. They retrude the atlas to significantly increase cervical stability. This hyperstability allows for dominant performance in the sagittal plane. These individuals may need more visual interventions.
She’s a Wise Woman
Dr. Heidi Wise gave one of my favorite presentations of the symposium. She discussed vision’s role in extension-driven individuals.
Vision is the most dominant sensory modality, as it has the ability to override all other senses to redirect attention. To me, this is why vision is such a powerful way to get someone neutral.
Redirection of attention through the visual system occurs through saccades. These eye movements occur 85% of the time our eyes are being used. This is how the visual system detects a salient stimulus.
If visual processes hold someone in an extension pattern, it may become extremely difficult to near-impossible to overcome.
Here is how we start thinking a visual process may be promoting an extension pattern:
Those who cannot inhibit extension with traditional floor-up activity.
Late-onset (past puberty) or severe near-sightedness.
People with extremely good eyesight.
Folks who over-focus on objects straight ahead (people who stare).
People who walk with purpose (makes me think of my mom in the mall!).
If someone over focuses (read: nearsighted), eye exploration is minimized. It becomes much harder to notice change, or salience. This is how the visual system can keep someone stuck in a stress response.
What is needed to see close?
Increases in acetylcholine and norepinephrine.
Reflexive increase in neck/head muscle tension. More so if one must strain to see.
Do this too long, and we can see unfavorable autonomic, visual, and neuromuscular stress.
And guess what visual field research is showing we better attune to? The right side; more specifically, the right upper visual field.
The PRI goal? We want to restore ambient vision in these individuals to process three planes of visual motion.
Here were some of Heidi’s recommendations for how to do so.
Take breaks from a task to move.
Be aware of surroundings on both sides without looking when walking.
Walk slower than usual.
Look around using your eyes independent of your head.
If nearsighted, take glasses off occasionally and “be OK” with things far away being blurry. Don’t strain to see well.
Have top of computer screens at about eye level. Look far from the screen as often as possible.
Close eyes and visualize a large open area that makes you calm.
Minimize time on small, close screens and keep object far from eyes.
Read books over e-readers and keep the book as far away as visually comfortable.
Emphasize peripheral awareness before and after high attention tasks.
Change variable such as sounds or environment during high attention tasks.
Strongest memories are tied to emotions; more negative than positive.
If the limbic system is too active (such as in a threatening environment), prefrontal cortex activity goes way down. You can’t learn as well.
Cranial nerves are extremely important in social interaction. Nonverbal cues from these areas can unconsciously affect autonomics.
During adolescence (12-25) the right side of the brain and limbic system develop faster than the left and neocortex. This lateralization is why this time period can be so emotion-driven.
Face to face interaction is needed to cultivate the nervous system. This is the problem with social media and texting.
Dopamine pathways are very active during adolescence; it’s one of the reasons addictions start during this time.
Feelings of being overwhelmed are 6 times more common in those who have had concussions.
Rehearse making mistakes and how you will come out of them.
He also provided some great patient interaction nuggets that I hope to liberally steal.
Keep your eyes on the individual and tell them “it’s great to see you here.”
If you are not doing well on a given day – “I don’t feel good today but we’re going to have a good session.”
If you are at odds with a patient – “We’ve seemed to come to a roadblock. Would you agree?”
My big takeaway from psychologist Dr. Tracy Heller’s talk was mindfulness.
Mindfulness is something I am hoping to get more into in the future. She defines it as being aware of your thoughts, emotions, physical sensations, and actions in the present moment without judging or criticizing yourself or your experience.
It’s a big deal to have this capability. Practicing mindfulness has been shown to reduced cortisol, stress, pain, depression, and anxiety; while also improving memory, sleep, and cognitive function.
The way we build mindfulness is basically letting go. I like the analogy that I heard while using Headspace (a great app if you haven’t used it). Imagine your thoughts and feelings as cars in traffic. Your goal is to just watch the cars pass by, not chase them. You want to be present in the moment, as we want in most of life.
One option of practicing this is resonant frequency breathing, in which we perform 4.5-7 breath cycles per minute. Let the body breathe on it’s own and let the air come in; using terms such as “let,” “allow,” and “permit.” These are cues I have been using much more with patients and has made a big difference.
This was easily my favorite part of the symposium (I may be biased since my Dad gave this talk). Bill Hartman blew it out of the park teaching us how PRI applies at the highest level of performance.
The rules change in the performance realm because the patterns are incredibly powerful, effective, and efficient. In some cases we may want them. A perfect example that Bill gave: Usain Bolt
Rarely does he cross midline when he runs, making him the fastest runner on one leg. Do we want to change that? Probably not.
Performance does not equal health. Gymnasts for example, may need to create pathology to perform at a high level. Some people must utilize passive elements to produce greater outcomes. Usain Bolt runs on one leg. Everyone is a case-by-case basis. N=1 forever.
What must occur in the performance and health realm is stress management. Acute stressors with recovery make us antifragile; prolonged stressors reduce variability as an allostatic adaptation.
If one must constantly perform at a very high level, where will they be on this stress dichotomy? Prolonged stressors = reduced variability, sympathetic dominance, and system extension.
Variability helps us anticipate demand. It helps us become better able to cope with specific environments and recover movement function. The only way we can know if movement variability is present is through assessing the musculoskeletal system
“The state of the musculoskeletal system is the other end of the brain” ~ Bill Hartman
If stressed or threatened, body systems use default reflexive mechanisms to combat threat. The brainstem is much faster than the cortex. As a consequence, variability can be lost.
Attaining increased prefrontal cortex activity allows us to inhibit our default response and increase variability. That’s why mindfulness increases HRV, and that’s why a 90/90 hip lift can alter body position.
To better manage stress, we must train. Training is a progressive desensitization of threatening input to allow an athlete to perform at adaptive potential with optimal variability and without fatigue.
The higher performance level required, the more difficult it becomes to get neutral. This is what happens during functional overreaching. You gain higher performance output during this timeframe because the sympathetic nervous system and HPA axis are on overdrive.
Applying Bill’s principles along the training and rehab continuum, rehab requires neutrality and variability to rebuild a failed stress tolerance. The amount needed in performance realm will depend on how (in)variant one’s sport is.
The Wild World of Combat
Dallas Wood and Zach Nott work with in a military population, and it was fascinating showing how they mitigate the extension necessary for their clientele to perform. They guys collect a lot of data, and the fun factoid was that about 80-90% of their individuals are PEC and bilateral BC (surprise surprise).
They showed us a very cool auditory case. They had a dude with a PEC/BBC presentation with a history of ear trauma and tinnitus. When they blocked his left ear the gentleman was completely neutral.
Treatment underwent reducing the tinnitus by implementing a hearing aid that uses various white/pink noises to slowly reduce tinnitus. Not sure exactly how it works, but this was exciting to hear about (ha). I look forward to learning where PRI takes auditory integration.
So there you have it. I already signed up for next year’s symposium because this one was so much fun. I look forward to more of the consistently fantastic content that PRI provides. Learn on!
Day three consisted mostly of putting the finishing touches on my quest toward neutrality.
The morning began by tweaking my gelb splint so I was getting even contact on both sides. This way I would be ensured to not have an asymmetrical bite.
I put a pair of trial lenses that fit my PRI prescription, and grinding commenced. We finished with this:
Once the splint was done, I had a final meeting with Ron to go over my exercise program.
I was placed into phase one visual training with two pairs of glasses. My training glasses were to be used when I lift weights, perform my exercises, walk around, etc. I could wear these for up to 30 minutes at a time; making sure I maximize my visual awareness of the environment.
While I was wearing these glasses, I was to be keen on finding and feeling my heels; especially when I turn my head. The glasses would help me find the floor, as well as help my eyes work together and independently from my neck.
My second pair of glasses was to be used while performing any activities within arms reach. This pair helps my eyes converge better and promote less eye fatigue.
Ron gave me several phase I vision activities as well as a few others. His main objectives were to get my eyes to move independent of my neck. We also wanted to create thoracic rotation on my rock-solid hip alternating capacity.
Here was my list:
The first activity helped with differentiating eye and neck movements.
The next activity was more alternating reaching in left stance; key is to keep eyes on left arm.
This beast below used a mirror to help me visualize doing the exact opposite pattern that I was trying to create; more visual tricks.
This next exercise utilized viewing the environment while using my alternating skillz
And here we have another very good alternating thoracic activity.
The Neutral Lifestyle
I’ve had my splint for a month, reading glasses for 3 weeks, and consistently using the training glasses for 2 weeks now.
In just that short amount of time I’ve noticed quite a few changes. Granted, there could be many influences as to why these things have occurred, but I’ve tried to minimize as few variables as possible.
This area is where I’ve noticed the most changes. My recent program block for the past couple months or so has been very aerobic based. I lift weight 3 times per week at mostly tempo style. The other 2-3 days I train consists of one day playing basketball for cardiac output and either high intensity continuous training on my bike and/or tempo intervals with a jump rope or sled.
Before glasses (BG), I was measuring my heart rate variability (HRV) and resting heart rate (RHR). These numbers have not budged much with the month or two that I have been training like this. But after glasses (AG), I have noticed general trends of my HRV being higher and my RHR lower.
The HRV changes are what impressed me the most, as I have had many more outside stressors occurring in this time period. So despite being in a higher stress environment, my HRV climbs.
In the weight room itself, the load I have been lifting has generally tanked. I have lost strength in many of the lifts that I was doing, yet I’m actually feeling more work occurring in the areas that ought to be working. My neck and back seem to be kicking in much less. This was a pleasant surprise. I also seem to get less tired during the aerobic stuff I have been doing. Again, these changes could be due to time, but most of these reports have not changed in the few months that my aerobic training has occured.
The craziest change yet? Without performing any true “jump training,” I was able to easily grab the rim on a 10-foot basketball hoop for the first time since high school.
I can also now perform a full deep squat unsupported, which is something I have been practicing since January. I was unable to do this until the second week AG.
Regular Life Stuff
Many more changes have occurred to me with just regular life stuff. I generally feel much more rested after sleeping, even if I get less hours than I am normally accustomed to. I also don’t seem to get as many afternoon lulls as I used to.
Reading. Oh My lanta. What a huge difference. I am retaining quite a bit more of what I read, and find that I do not get eye fatigue. Like, at all. Even if I am on the computer for a very long time.
Neck tension has been variable. I notice quite a bit less when I am reading, but I still tend to feel it if I am away from my orthotics, driving, or extremely stressed. The frequency this tension is present is quite a bit less.
I do still get some jaw clicking with opening, but the gelb splint seems to decrease this frequency quite a bit.
Overall, I generally just feel good.
I have had a lot of people ask me why I went through this process, especially if I do not have pain. Curiosity and need for completion drove me there, but I left with so much more than I thought I would ever get.
The nervous system craves three things: movement, space, and bloodflow. As a PEC with limited mobility in every plane, my system was not getting space. Less space increases stress to my nervous system, which may or may not have led to many possible outputs.
Pain is only one of many outputs that a system under threat could produce. Perhaps an output could be hypertension, dizziness, fatigue, heartburn, decreased attention, inability to learn, constipation, anxiety, depression, etc.
Maybe even a decreased vertical jump could be an output in response to system threat.
Likely anything that has a large contributing factor from our normal stress response could be affected favorably by decreasing system load through achieving neutrality.
It is here that I feel PRI is leagues beyond any other treatment methodology, and could potentially have impacts beyond pain; something many conventional PT methods may not always address. It is not because these methods are bad or do not work, but it is because they are only addressing a few pieces of the human system.
PRI is the only framework I have seen that addresses and explains most completely how the human being functions under threat.
Does that mean PRI is going to cure everyone’s problems? Probably not. Some conditions could be too far gone, some may have causes/effects beyond our normal stress response.
You cannot know if something will be helped or harmed by PRI until you take the autonomic nervous system out of the equation. And that is how I believe PRI works.
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.”