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Category: Assessments (Page 2 of 3)

WTF is this PRI?

Most of you who read my blog already know what it means when I say PRI. There is some misconception around the internet as to what PRI can do for you and where it fits into your treatment model as a strength coach, personal trainer, chiro, physical therapist, or whatever you do.

PRI comprises the bulk of my assessment and reassessment protocol for new clients. It is the base of my methodology. Eric does a great job of explaining the thought process in a way that is much more articulate than I could ever hope to convey.

The foreword below is Bill Hartman, and the information is courtesy of Eric Oetter, who writes from the perspective of physical therapy and strength & conditioning. The post speaks for itself and I share it here because the content needs to be disseminated to the masses. Pass it along.

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BH: “This a post from our boy Eric Oetter. It’s probably the best written synopsis of therapeutic intervention with an understanding of the role that Postural Restoration Institute methodology and other tools play in the process. It needs to be passed around to everyone especially those responsible for educating the next generation of clinicians and practitioners. Please share.”

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It’s becoming increasingly clear that the path to system variability and pain-free movement is gated by neuroception (i.e. limbic threat appraisal) and autonomic nervous system output. And its these two properties of the nervous system which govern the effects of the innumerable methodologies therapists use to expunge system rigidity.

Autonomous of discipline or method, clinicians intervene at the level of the receptor (rods, otoliths, mechanoreceptors, etc.), engendering unique signal transduction and transmission into a sea of equal status patterns which participate in collective summing within the brain.

We’d hope our therapeutic inputs contribute to a modification in the perceptive capabilities of the patient, though (as we all know) this is not always the case. Some inputs never reach the level of perception while others exceed the adaptive capacity of an already rigid system, perpetuating chronic limbic hijack and sympathetic dominance.

But a positive change in perception opens valuable cortical real estate for neuroplastic remapping via graded exposure, which is the substrate for system variability. This is really the goal of any physical therapy intervention.

So, how do we know we’re dealing with a rigid system in the first place? And furthermore, how can we evaluate the efficacy of our inputs with respect to restoring system variability?

Beyond many other “systems” I’ve experimented with, PRI seems to provide the most cogent answers to the above questions. And it’s the “umbrella” which explains, to me, why other methods work.

What PRI provides is a means to identify a predictable pattern of ANS-mediated anti-gravitational motor output for a collection of systems held in some degree of rigidity. The perspective they bestow is quite comprehensive; PRI is a unified system respective of ALL sensory inputs capable of influencing reticular output (mechanoreception, vision, audition, etc.).

But woven through its complexities, their simple orthopedic testing and treatment algorithms provide a reliable means to assess this aberrant output, as well as evaluate the systemic and perceptual perturbations that might follow any therapeutic intervention (PRI, Mulligan, Maitland, MDT, ART, etc).

Because interventions can be both synergistic or antagonistic to the pattern PRI presents, utilizing a withdrawal A-B-A study design during a treatment session (with the patient functioning as their own control) upholds an element of internal validity beyond what other systems might be able to provide. I’d argue this makes PRI a powerful adjunct to anything you’re already doing, as we scrounge for external validity in a increasingly heterogeneous population.

PRI treatment aims to recapture reciprocal and alternating movement in three planes across the three girdles of the body. And PRI is never about fixing posture – it’s about restoring system balance, variability, and adaptive potential.

Defining Neutrality

One of my goals for my non-athlete athletes (the teachers, moms, doctors) is neutrality.

But what does that even mean? What’s not neutral about me?

It’s reminds me of the intro in Van Halen’s “Hot For Teacher”. I don’t feel asymmetrical.

I don't FEEL asymmetrical

 

Asymmetry is Natural

Forgive the morbid visual, but if you cut yourself right down the middle and looked at your right and left insides, no part of your rational brain would think, “I’m a perfectly symmetrical human being.”

And what does that make you? That makes you and I part of the same Homo sapiens family. That’s it. Asymmetry isn’t weird, it’s normal. It’s necessary.

The biggest internal asymmetries that I like to point out to clients are the size of the thoracic diaphragm, the side of the liver, and side of the heart. These make us really good at standing on our right legs and breathing into our left chest wall.

Where's the left liver?

 

And going back to Van Halen, most people I’m cuing won’t feel asymmetrical until I get them neutral. If you live a life on your right leg (hint: you do), you’d feel weird on your left leg, too! Remember the story I wrote about from that course a few weeks back?

 

 

The Origins Project

It’s impossible to say where or why or how this asymmetry has come about to be so prevalent, but I can make a guess (because that’s what the interwebz is so good for: speculation).

It makes sense to me that this asymmetry has come about from natural selection, just like, you know, everything else. The infamous Pat Davidson recently shared a quote with me that sheds some light on the topic from the point of view of a physicist.

“…right-handed DNA for all is the rule. Evolution plays an essential role in this. As only like spirals can link to make a double helix, there is no advantage if some of us had right and others left, or if we had a mix of both. It appears essential for effective procreation, that the half provided by the male matches that from the female, and the most efficient way is if they have only one and the same handedness. While this does not explain how and when the asymmetry in the amino acids of our DNA originated, evolutionary advantage aided by the vastness of time could be the cause.”
-Frank Close, “Lucifer’s Legacy”, p. 76

If you think about the beginning of life on Earth, making two sets of DNA would, at best, halve the chances of life forming. So these all-right-sided DNAs had a huge advantage in making copies of themselves.

 

Defining Neutrality

If I go any further on origins, I’ll be stepping out of my bounds of education, so let’s shift gears. What am I examining to see whether or not you’re neutral?

Well, as someone who works with bodies and weights, the best way I know how to attack the situation is through movement. Even though not every change is orthopedic, these changes are the most tangible to you and I.

So I do some tests. I look at the position of your lower body with an Adduction Drop Test. This will tell me a lot, but most specifically, it tells me the position of your pelvis. Can you adduct?

There are some other accessory lower body tests that I’ll do to confirm my findings because I mess up sometimes. Hip motion tells me a lot of things.

Then I do some tests to look at the position of your upper body. An Apical Expansion test is the first time I ask you to breathe for me. Can you exhale on the left side? Can you inhale on the right side?

Then I’ll confirm my findings, which I find is especially important for the Apical Expansion test because it’s hard to judge the results without tester bias. Shoulder motion tells me a lot of things.

I always look at the way your neck moves, too. This Cervical Axial Rotation test is important because your neck motion tells me a lot of things.

If I can get all of these tests cleared, you’re neutral. If you’re neutral, you can effectively move side to side. You can walk with two legs instead of a right leg and a left kickstand. You can aspire. You can create.

Based on the natural asymmetry I was talking about earlier, I’m able to make some test predictions. If all of these predictions prove correct, I would call you “classic”. A classic left AIC, right BC, right TMCC. A classic human.

Then I can give you an exercise or push on your ribs to help you get neutral.

 

The Epilogue

After you get neutral (note the wording; I’m not doing it, you are), I give you some homework to make it stick. Neutrality isn’t a forever-defined state.

This reminds me of a tenured client I’ve worked with many times at IFAST. She got neutral months ago and was so proud of the progress she’s made. I imagine me watching this is what it feels like when parents see their child walk for the first time.

Then she got busy at work, started sleeping less, eating worse, not coming into the gym consistently, and getting neck problems. I was able to look at her one-on-one and found out that she’s not neutral anymore. What gives?

The state of your system is dependent on so many factors: what you see, what you hear, the exercises you’ve been doing, what has happened to you in the past, who’s around you… Any perception of threat steals your neutrality and puts you into survival mode. What happens for someone like our client in this case is she forgets what it feels like to be neutral. My job is now to remind her. But how?

For some people who aren’t too far locked into the normal, asymmetrical pattern, the task I give you might be to find your left heel a few times a day while you’re at work. This could be enough to remind your body that you have a left side that likes attention, too.

For most people, I’m going to give you some exercises to do at home and in the gym. You may have years of adaptations and compensations that we need to combat, and those tests I listed above tell me which of these we should focus on. And if you’re trying to get stronger and healthier, these exercises can help mitigate the negative effects of weight training.

Most commonly, I see a locked up pelvis on both sides because I see people who like to lift heavy things. If this is you, part of your program is going to be opening up the outlet of your pelvis. As I tell my anatomy students, this makes it so you can poop. Though this is hilarious to tell people in public, it’s not the only side-effect. Remember Bob Ross?

Then we’ll follow up with a lot of reaching activity. If the butt is closed off, so is the back. Active reaching helps make things stick better.

Then I might give you an exercise that reminds your body how to work as one whole system; an integration exercise. Moreover, I’d like this exercise to be done while standing, because you’ll be standing when you’re going about your daily life without me. I want to teach my baby birds to fly.

This pathway isn’t set in stone, it’s just a blueprint. Some people get different homework. Some people get the same homework for different reasons. Some people get the same homework for the same reasons.

That’s just a quick primer on neutrality. If you know someone at the White House, can you suggest to them that we make the first 24 hours of winter Neutrality Day? Neutral people welcome the winter because they have bodies that can deal with change.

Do you welcome winter?

Before you leave, do me a favor:

  1. Send this article to the last person with whom you talked about neutrality.
  2. If you haven’t yet, subscribe to my newsletter to get the information I don’t put on the blog.

And as always, comments and emails are always welcome.

All the best,
Lance

More Research Linking the Feet and Head

In a previous post, I discussed some of the research done by Dr. Brian Rothbart, a Doctor of Podiatric Medicine (DPM), which shows a definite relationship between the feet and the head.

In response to what I wrote, Dr. Rothbart added a comment citing some of his more recent research.

After reading the paper, I wanted to go through it with you guys.

The Case Study

Rothbart examined four subjects with cranial radiographs. These pictures were taken (1) without intervention, (2) with a prescribed dental appliance, (3) with some sort of foot orthotic, and (4) with both interventions.

Two of the subjects saw the most improvement when using both interventions. Check out the example below.

Baseline
After intervention

Very cool stuff. But what about the other two subjects?

The Meat and Potatoes

Subject AD saw worsening when using both the dental appliance and the foot orthotic. The confound here, and why this study offers so much, is that AD was not using Rothbart-prescribed insoles, only generic ones.

The author used this piece of evidence as a very important talking point: keep a global view helping someone. He suggests that generic insoles, like the ones AD used, may alleviate feet symptoms while increasingly destabilizing the cranial bones and potentially lead to headaches. This outcome was noticed in AD and is a classic demonstration of treating the symptoms, but not the problem.

Check out two of AD’s radiographs below. Take special note of the second from the bottom (level of the mastoids) before and after intervention.

Subject AD baseline
Subject AD cranial destabilization after intervention

Subject HB was described to have blocked sacrum. This concept makes sense when you see that the data showed improvements with the dental appliance, but not the prescribed proprioceptive insoles; there was a break in the chain.

The treatment of HB is another demonstration of the importance of maintaining a global view. It also illustrates, however, the need to clear up restrictions. As the author mentions, ankle problems may be fixed, but the subject had increased low back pain.

As Rothbart summarizes: “In both of these cases, from a strictly podiatric point of view, the proprioceptive therapy might be considered successful. But from a holistic point of view, the proprioceptive therapy would be considered inappropriate.”

Summary

Keep in mind that this is all my interpretation of the research, but I’d say it definitively shows a link between the head and feet. Care to offer anything? Add it in the discussion below!

Tips to Aggravate Your Shoulder

Overhead pressing requires good mechanics

The shape of the glenohumeral joint lets the shoulder move. A LOT. This mobility, however, means that stability is lacking. Plus, it contraindicates some exercises right off the bat. Educate yourself and don’t let ignorance destroy your clients.

Factors Contributing to Shoulder Instability

Without even considering those who have genetic predisposition to floppy shoulders, the “normal” shoulder is already unstable in the grand scheme of joints. The glenoid/”socket” of the shoulder is shallow. Much more shallow than the acetabulum/”socket” of the hip. This lets us reach overhead, but does little to contain the arm.

The scapula, which holds this shoulder socket, is suspended by muscle, not locked into place by the shapes of the bones like the more stable knee and elbow joints. Force couples from muscles surrounding the scapula are everywhere. If not balanced, this will cause even more problems.

And the muscles that control the scapula are only affecting the scapula. The scapulospinal muscles, such as trapezius, also connect to the vertebrae and pull on the spine. If you fixate the shoulder and shorten the trapezius, the spine rotates contralaterally. So the spine has to be stable if the scapula is going to be stable if the shoulder is going to be stable…

Looking in the distal direction, that big, dumb muscle that everyone loves, pectoralis major, doesn’t attach on the scapula. But can it control the scapula? You betcha.

Superficial muscles of the chest and arm

One of the proximal attachments of pec major is on the clavicle, which articulates with the scapula at the acromioclavicular joint. Moving the clavicle orients the scapula. The distal attachment of pec major is on the proximal humerus (around the armpit). Pulling on the arm can orient the glenoid to face inward and downward. This big muscle works better as a prime mover, but can act pathologically as a stabilizer of the shoulder. When this happens, the mechanics of the shoulder joint don’t work very well, i.e. the ball doesn’t stay seated in the socket.

To beat down pec major even further, imagine a client with anterior instability of their shoulder. Now make them do push ups to failure and tell them to make their arms long at the top of the movement. You know, to get serratus. This protracted position makes the glenoid point forward. Pec major keeps working to get me up on that last rep, but pec pulls the humerus forward and inward. This client doesn’t have a capsule to check the anterior glide of the humeral head, and pec pulls the shoulder right out. This is an anterior dislocation.

Don’t coach your clients into dislocation.

This is why a proper assessment is a necessity and why trainers need to take education seriously. You can never know too much anatomy.

How Does Instability Lead To Pain?

Normal roll-and-slide mechanics of the shoulder joint keep it centered in the glenoid. When the humeral head becomes unstable, this centralization is easily lost when demands are placed on the shoulder (e.g. when pec starts to do it’s dirty work).

If you start the lift the arm overhead, the subacromial space can be closed. The humeral head rolls upward, and if no inferior glide accompanies this rollw, it doesn’t stay in the center of the glenoid and an external impingement occurs where the subacromial bursa and supraspinatus/infraspinatus of the rotator cuff rub on the acromion of the scapula.

This instability, however, doesn’t have to be localized to the glenohumeral joint. Instability at the scapula is drastically more common and also destroys the shoulder.

Lateral Raises

Bros everyone love the lateral raises. These, however, are not the only way to develop your deltoids. Plus, they give a lot of people the external impingement we just talked about because normal roll-and-slide mechanics are lost when deltoid takes over as a prime mover AND a stabilizer. Remember our talk about pec major?

We also have to consider the shape of the humerus here. The greater tubercle is a bony bump that sticks out anterolaterally. When the arm is brought into 90 degrees of abduction, strictly occuring in the frontal plane, this greater tubercle is much closer to the acromion and makes impingement easy. The orientation of the glenoid also points forward, making it’s front side more open to the world. Externally rotate the shoulder into a “high five” position and you push the humerus even more forward. It’s much less likely that the shoulder stays seated in the socket.

Abduct the arm without an inferior glide and that acromion will become a percussive instrument

A quick fix for this positioning is to stay out of the frontal plane and move to the scapular plane (about 30 degrees anterior to the frontal plane).

Remember, it doesn’t just have to be a lateral raise. An overhead press in the frontal plane is the SAME position. Pack the shoulder down and back and swing the elbows a little more forward and you get immediate relief by opening up the subacromial space.

Behind-the-Neck Pulldowns

This exercise requires an extreme amount of shoulder extension and external rotation. Both of these will throw the shoulder forward and lead to more anterior instability. Remember those anterior dislocations we were talking about?

What is wrong with a normal pulldown or pullup? Variation for variation’s sake is unnecessary if it’s doing damage. Vary your set and rep scheme before pushing your shoulder to end range of motion.

Overhead Throwing

Baseball pitchers all have shoulder problems. Most know this, but it illustrates another mechanism for injury I want to discuss.

SLAP (superior labrum from anterior t0 posterior) lesions are quite common in overhead athletes. This is where the long head of the biceps brachii comes into play. The tendon of this muscle rides between the greater and lesser tubercles, around the top of the shoulder joint, and ends up connecting at the top of the glenoid on the labrum. Forceful contraction of this muscle pulls on the labrum, and in the case of pitchers who need a lot of force to slow their arm down, long head of biceps can pull the labrum right off.

The long head of biceps brachii attaches to the superior glenoid labrum

The glenoid labrum gives the shoulder more stability by increasing surface area and sucking the humerus into the socket. Compromising this tissue further compromises the integrity of the joint.

Summary

Stability is important for joint longevity. Due to the regional interdependence of the body, stability needs to be attained everywhere for the shoulder to work well. Without this, shoulder mechanics become pathological. Dysfunction and pain are quick to follow. Exercise selection is never as simple as, “This worked for me, so you should do it.” Understand anatomy so that you don’t destroy joints.

Impingement and Instability – A Recap

Last updated: July 18, 2021

I spent this past weekend in lovely Phoenix, Arizona to reunite with old friends, meet the legend that is James Anderson, and learn all the things. Check out the Twitter action.

Phoenix is seriously 40 degrees warmer than Indianapolis and seven thousand less percentage humidity, so I was immediately caught off guard. Though I didn’t have my physical therapist friends test me right away, I’m pretty sure the unpredictable environment would have stolen my neutrality, had any remained after four and a half hours on a plane.

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