My trip to PRI's Postural Respiration Course
I recently attended PRI's Postural Respiration Course in Salem, OR. I had initially heard of the Institute and it's courses through the Strength and Conditioning community, and so when I had an opportunity to hear Ron Hruska interviewed by Joe Heiler on Sportsrehabexpert.com earlier this year, I jumped at the chance to hear him speak. I came away from that interview believing that I was listening to a very sharp guy, but at the same time thinking that it was all maybe a little crazy. A few months later I sat in Georgetown with an old friend from PT school at the wedding of a classmate and inevitably, talk turned to shop. I should note that Hruska struck me as a very smart guy based on an interview, but I KNEW that this girl was sharp. Great clinical skills, very well educated and generally skeptical in a good way: Heather Carr DPT (and a host of other letters after her name) possessed a great Bullshit filter. And she was raving about PRI. She told me she planned on attending all of the courses with the goal of not only becoming certified in the method, but to become an instructor. This is a clinician who has invested a lot of time and money into her skills and she had never been as excited by a treatment approach as she was about PRI. She even started a google group. That same trip, I had the pleasure of visiting Drive 495 in Manhattan and spoke at length to a young Physical Therapist, Connor Ryan, who had a similar enthusiasm. A combination of interest and the practical sense of a need to at least be able to speak on the topic so many smart people were talking about encouraged me to sign up for the May Course.
James Anderson was the very dynamic speaker (Kyle Keisel, one of the creators of the Selective Functional Movement Assessment and my instructor at a 2009 SFMA course in NJ was a fellow student, which was a bit of a kick). James took a great deal of challenging information and kept it interesting throughout the two days, however as I tried at the end of each day to distill what the theory was and how to apply it to practice to my wife and another colleague (both PTs), I failed at both. I have since delved deeper into the literature on PRI (and consulted with the folks from the Google group, who are a helpful and enthusiastic bunch) and would like to share what I have learned.
The general concept of the Postural Respiration Institute is that the human body, which is inherently asymmetrical, is balanced through integration of the imbalances. The primary example cited in the respiration course is that the left diaphragm is both weaker and biomechanically and structurally disadvantaged relative to the right diaphragm. This results in a right rotation of the pelvis and lumbar spine, with an incomplete corrective rotation of the thoracic vertebrae back to the left. Other examples include a tendency for people to stand mainly on the right lower extremity, and overuse of the right upper extremity for communication due to the left brain’s responsibility for speech and language. PRI focuses on minimizing these asymmetries to the point where they do not lead to pathology. Additionally there was an emotional and unequivocal takedown by James of the current fashion for improving thoracic extension due to the anatomical compression of the sympathetic ganglia with excessive trunk extension, as well as links to hyperinflation of the lungs, stress, GERD, etc.
Key Definitions for this Particular Course:
Zone of Appostion (ZOA): This refers to the portion of the diaphragm that lies against the inside of the ribs and acts as a piston, pulling the dome of the diaphragm down with inspiration (Side note: There are some definitions that are exclusive to PRI. Since I had never learned the term in Gross Anatomy or PT school, I started looking for other references. Sure enough, I found one in a nasty little 1996 experiment published in the Journal of Applied Physiology that involved paralyzing beagles and suturing lead markers to their diaphragms). In a human with a sub-optimal ZOA the portion of the diaphragm in contact with the ribs is decreased, resulting in hyperinflation of the lungs and excessive extension of the trunk. A big part of this course involves restoring the ZOA to it’s optimal position.
Brachial Chain (BC): This is a group of muscles influencing cervical rotation, shouder movement and upper chest expansion and include the triangular sterni, SCM, scalene, pec minor, intercostals and Sibson’s Fascia.
Anterior Interior Chain (AIC): This is a group of muscles that exert a significant influence on respiration and rotation of the trunk and lower extremities and include the diaphragm, the psoas, the iliacus, TFL, biceps femoris and vastus lateralis. James also encouraged us to think about it as a ‘swing phase’ chain during gait.
Posterior Exterior Chain (PEC): This group was not discussed at all in the course itself, though the course materials state that it includes the multifidi, the QL, posterior intercostals, Serratus Posterior and iliocostalis lumborum. Their extensor functions thus make it another muscular chain to be inhibited rather than enhanced in light of the general animus towards extension in this model.
The three latter definitions are exclusive to PRI, and though other therapists have looked at polyarticular chains in the past in their relation to function and pathology (Thomas Myers’ “Anatomy Trains” model will be the most familiar concept to many), a big complaint I had with this course was the failure to discuss how and why these individual muscles were grouped together into functional units. I spent the evening after the first day trying to piece together the answer to that question and was unsuccessful. The best specific question I could come up that might lead me in the direction of an answer with was to ask why the vastus lateralis was included in the AIC. The answer was through its action of femoral external rotation. When I pointed out that my understanding was that hip ER was a function that the Vastus Lateralis did not perform, it was suggested I take the Myokinematics Course to find out how it did perform said function. Later that night my discussion partners and I riffed on all sorts of ways that environment and anatomy might serve to make this possible; however my personal feeling is that when educating it is necessary to explain the thought process behind a statement on functional anatomy that traditional anatomy implies is impossible.
No one else questioned this however, which led me to feel simultaneously 1) not intellectually up to the task, and 2) the only sane person in a room gone mad.
Now What?
The Primary Goal of this course was to address an excess of what PRI describes as a normal pattern of human asymmetry, the Left AIC/Right BC pattern, where the pelvis, lumbar spine and diaphragm are rotated to the right and the thoracic spine and rib cage rotates back left (but not completely back to the frontal plane). There is a remarkably simple set of tests for diagnosing the AIC hyperactivity of this condition, including tests that measure Apical expansion and trunk rotation, as well as tests that are very similar to the Thomas and Ober tests. Unfortunately, the clinical reasoning behind these tests was not identified. If the tests are positive, there is a set of exercises that are prescribed, most of which variations of the now-familiar 90/90 bridge. Similar to correctives prescribed in Functional Movement Systems, there should be a measurable improvement in the test findings immediately following performance of these exercises. If there is not, manual treatments are performed. The manual techniques were very effective at obtaining an improvement in the test findings, both when I performed them and when other students performed them on me. Next, there are five tests to diagnose the BC portion of this pattern, one of which is the Apical Expansion test from the AIC. There was a detailed and very elegant reasoning outlined for the selection of these tests in the course materials, which was helpful. The BC has gotten a lot of traction among the strength and conditioning community as one test measures Glenohumeral (humeroglenoid?) internal rotation. Again, there are both non-manual and manual techniques presented for treatment of this condition and the manual treatments can seem like magic in improving this GH IR in some people.
There are also treatments for an additional compensation to the typical right BC pattern called Superior T4 syndrome.
Locking it In
The disappointing (and in retrospect, unsurprising) thing about the manual and non-manual treatments was that revision to previous impairments and patterns occurred quickly after treatment was completed. Easy come, easy go. This comes as no surprise to anyone who has ever made great changes in a treatment or training session and seen the client return nearly to square one by the following visit. This is where repetition of the exercises at home, as well as avoidance of aggravating postures comes in. I do wonder about the application of PRI exercises (aside from those designed to improve rib cage expansion) in an athletic population. An appropriate and regularly practiced training program will decrease the effects of the muscular asymmetries that develop from asymmetrical postures (unless they are reproduced consistently during a workday, for example), and if they do not, and strength has been placed atop dysfunction, I wonder about the effectiveness of exercises like 90/90 bridge variations or seated tricep extensions in altering muscular activation patterns in someone who has a history of heavy deadlifts or bench presses. Admittedly I have yet to try most of the non-manual treatment techniques on clients yet, because I received the good advice to only try and master a single manual and non-manual treatment at a time, and also because some of the specifics don’t make much intuitive sense to me. For example, in addition to its functions as a scapular upward rotator and abductor, the serratus anterior is also identified as performing the following additional actions: pulling the ribs posteriorly to the scapula and directing the torso to the contralateral abdominal wall. While it is certainly true that both origin and insertion exert an equal force on one another, I kept thinking about how when I throw a baseball into the air, the mass of the ball exerts a gravitational force on the earth, pulling the earth to the ball. I know it’s true, but the real story is the one about the earth pulling on the ball. Likewise, it seems to me that the scapula, floating over the ribcage with its only real articulation at the clavicle, is at a real disadvantage when it comes to displacing the trunk.
The critical points made above should not only be recognized as coming through the lens of someone who has not yet tried a good portion of what is a very comprehensive system (there are 10 courses, and more appear to be coming), but should also not diminish the illuminative power of some of the techniques. I have heard multiple Physical Therapists refer to the tests and treatments as ‘Parlor Tricks’, which may be true. To return to the humeral IR example, the rapid improvement is clearly very transient. However, the rapidity of it also calls into question the validity of the common approach of increasing it by mobilizing and stretching the shoulder structures themselves.
As with all treatment models, there are holes, and as with all models, the approach is probably not suited for everyone, practitioner or client. There are however techniques and concepts here that deserve further exploration and I would encourage people who are curious about the approach to consider taking a course or spending some time with someone who has.