My Cognitive Dissonance with PRI

Last month I took my first Postural Restoration Institute course entitled Myokinematic Restoration. For those who are unfamiliar with Postural Restoration Institute (PRI), the best way I can describe it is that it is an approach that focuses on correcting natural physical imbalances of the body that lead to asymmetrical patterns of movement dysfunction. First developed by physical therapist Ron Hruska in 2000, I had been hearing more and more about PRI in recent years and noted that many rehabilitation professionals whom I respect and whose written content I follow employed its usage. I felt like it was gaining more and more popularity in both the rehabilitation and personal training worlds, and also that there seemed to be some anecdotal controversy regarding its foundations and principles. Up until now I had only read reviews of various PRI courses and believed I needed to take a course firsthand to draw my own conclusions regarding their methods. Like most continuing education courses these days, the subject material and basic PRI philosophy was also not covered in my physical therapy school. After the course ended, I don't think I've ever experienced such cognitive dissonance over a rehabilitation approach before--I wanted to accept PRI wholeheartedly but it was hard for me to do so at the end of the weekend. This following post will be my personal review of the course and I'll flesh out my thoughts regarding stuff I liked, stuff I didn't like so much and some stuff in between.
 

What is Myokinematic Restoration, Anyway?

Myokinematic Restoration is one of the three "primary courses" offered by PRI which serve as introductions to their philosophy and must be taken before delving into their more advanced coursework. The following course description is from the PRI website:

This advanced lecture and lab course explores the biomechanics of contralateral and ipsilateral myokinematic lumbo-pelvic-femoral dysfunction. Treatment emphasizes the restoration of pelvic-femoral alignment and recruitment of specific rotational muscles to reduce synergistic predictable patterns of pathomechanic asymmetry. Emphasis will be placed on restoration, recruitment, and retraining activities using internal and external rotators of the femur, pelvis, and lower trunk
— www.posturalrestoration.com

I probably read this a dozen times when I was considering signing up for this course before feeling like I understood it! In a nutshell, the Myokinematic Restoration course is based on several physiological facts or assumptions (not an exhaustive list):

  • In general, most people have a dominant postural presentation called the Left Anterior Interior Chain (LAIC) pattern: The left pelvis is anteriorly tipped and forwardly rotated (in the transverse plane).
  • Other common presentations as a result of the LAIC include elevated anterior ribs on the left, depressed shoulder/chest on the right, posterior rib hump on the right and overdeveloped lower right back muscle.
  • Muscular fibers of the diaphragm extend more inferiorly upon the right side of the anterior lumbar spine and predispose us posturally to rotate to the right.
  • Our livers are positioned on the right side of our body which also contributes to this directional rotational pull to the right side.
  • The left side of the diaphragm which is much smaller than the right cause the abdominal muscles on the left side to become weak.

I was aware of some of these anatomical observations from my cadaver dissection labs in grad school, but never have I encountered a school of thought in which predisposed movement asymmetries based on these were so discretely defined. These observations were established early in the course and served as foundations for more advanced concepts and treatment rationales. 

My first resistance towards PRI started here. I was concerned that if I had trouble accepting these foundational assumptions off the bat, would I be able to intellectually accept/apply other PRI interventions? Here's a picture of the "overactive" muscles of the LAIC:

From the "Essential Anatomy 5" app created by 3D4Medical. The different sizes of the left dome and right dome of the diaphragm and the slip of muscle which you see extending down the front of the spine are physiologic foundations on which many PRI principles are formed.

From the "Essential Anatomy 5" app created by 3D4Medical. The different sizes of the left dome and right dome of the diaphragm and the slip of muscle which you see extending down the front of the spine are physiologic foundations on which many PRI principles are formed.

I can appreciate that there are natural visceral and musculoskeletal asymmetries between the right and the left side of the body, but to what degree can we assume these asymmetries are the cause for such specifically defined movement dysfunctions of several muscle groups across various joints of the body? Due to copyright issues, I won't be able to directly quote material from the course manual on this post, but there is frequent mention of how chronic muscle overuse, respiratory problems, limited airflow, weakness in specific parts of the abdominal wall, inflammation, scoliosis and fibromyalgia are all results of the LAIC pattern.
 

The Problems Continue

To me, the problem with tying anatomy too closely into pathology and dysfunction is that it's too rigid of a framework. Under PRI assumptions, a patient who presents with piriformis syndrome on the left side should be treated differently than someone who has it on the right side. Depending on the side, different muscles and different joints should be targeted for treatment due to different treatment goals. I'm not convinced that the treatment approach outlined by PRI can confidently make these assumptions for this diagnosis, which can present in a multitude of ways (peripheral neuropathy, referred by the lumbar spine, etc). Similar examples were outlined for "ilio-sacral strains" and hip bursitis.

A big part of Myokinematic Restoration treatment was being able to specifically target very specific structures, which also piqued my skepticism. It seems that a large part of PRI is being able to detect which muscles are activated and which muscles are inhibited to extremely acute detail.

Not just whether or not a gluteus maximus is firing, but whether the anterior fibers of the gluteus medius specifically are firing.
Whether or not internal abdominal obliques are engaged enough.
Whether or not the "left abdominal wall" is engaged.

To me the problem with this is very apparent and raised so many questions:

  • How much visual acuity must one have in order to see this kind of specific EMG activity?
  • How sensitive must someones tactile touch be in order to differentiate between the anterior fibers of a gluteus medius versus, say, the posterior fibers?
  • What is the minimal effective dosage of EMG activity in a given muscle to produce the desired muscle contraction?
  • To what degree must the discrepancies be between the transverse abdominis, internal/external abdominal obliques and rectus abdominis be before a core musculature contraction is considered "dysfunctional"?
  • Is there a non-pathologic degree of muscular asymmetry that is allowed? 

Focusing such a specific lens on morphology and kinematics might be effective in certain situations for neuromuscular re-education, but sometimes the goal should be just getting the desired task done under less specific parameters.
 

Some Positives

In general, I think the basic messages of PRI are sound ones. The human body is able to perform movements in somewhat predictable patterns. Sometimes these patterns can be more prevalent on one side than the other. We have a pretty good idea about the actions of muscles and what they do upon certain joints. Maybe by influencing our muscles through corrective exercises and/or through positioning, we can thereby change the way our bodies move through these aforementioned patterns. Based on the goal of the client/patient and the role of the PRI practitioner, whether he/she be a health care professional, personal trainer, strength & conditioning coach, we can encourage particular movement patterns while discouraging other ones. This is all well and good, and I like this about PRI--I mean, is this not the essence of physical therapy?

In my opinion some of the course's main strengths were the many exercises that placed patients in specific positions to encourage certain neuromuscular behaviors. I believe some of these can be very effective for correcting hip shifts during squats. However, I do think there needs to be more of a critical thinking process when it comes to evaluating an individual's movement and not automatically jumping to the conclusion that Muscles A, B and C are overactive, Muscles X, Y and Z are inhibited, and therefore this joint is externally rotated relative to that joint, and all this is because a small sliver of the distal attachment of the right sided diaphragm extends a bit further down on the spine than it does on the left.
 

What About Pain?

I'm not really sure how the role of pain treatment fits into all of this. In Zac Cupples' review of the same course (taught by a different instructor), he mentions that his instructor literally stated that "PRI does not treat pain." This was not mentioned in my course, despite spending a considerable amount of time treating various pathologies like piriformis syndrome, tibial stress fractures, pubalgia, etc.  Rather than treating pain directly, the goal of PRI principles is to achieve a state of "neutrality", in which one can freely transition in between reciprocal patterns of motion without being compromised by faulty movement patterns.

This was also tricky for me to accept, as mitigating pain is a tremendous goal of almost all the patients that I see. Does someone being in pain make it such that I can't utilize PRI principles at all? Probably not, as I don't think PRI claims to be entirely comprehensive as far as treating pathology goes, nor do I think physical therapists treat their patients using only PRI methods. However, this does potentially complicate the clinical treatment approach of a health care practitioner whose patients are trying very much to get OUT of pain.
 

Final Thoughts

To use a popular metaphor, I definitely think certain PRI principles and interventions can be effective tools in the proverbial clinician tool-box. I just found it hard to reconcile certain foundational principles that in my eyes were reinventing the wheel and operating on a different treatment paradigm than most other philosophies I've encountered. If you're a physical therapist, chiro, or trainer and you disagree about PRI being as "unconventional" (whatever that means) as I've made it sound, that's fine too. There's going to be a lot of differences in thought depending on your educational background, values, professional scope of practice, business model, clients' goals and other treatment approaches that you subscribe to. However, there also needs to be some professional accountability with approaches like PRI that puts forth a lot of pathophysiologic assumptions for which I think many of my criticisms are valid or at least warrant more discussion. 

As of now I don't plan on taking another PRI course, but being an open-minded clinician I'm willing to change my mind in light of emerging evidence or observing clinical outcomes that might convince me otherwise.
 

2017: Cool Stuff to Read, Part II

If you live in the Northeast, are snowed in today like me and are in the mood to do some reading, here's Part II of my Cool Stuff to Read! (Part I can be found here).

Sports

While recovering from surgery, J.J. Watt walked twelve miles a day because that's all he was allowed to do at the time. An impressive feat requiring tremendous discipline for a monster of an athlete who can power clean 400#, squat 700# and bench press 500#...for reps. Imagine the psychological benefits one can receive walking 12 miles a day, rehabbing from a state of little-to-no strenuous activity back to the upper echelons of professional football.
http://thelab.bleacherreport.com/jj-watt-reloaded-how-the-dominant-d-end-rebuilt-his-body-for-the-long-haul/
 

Don't sleep on Chef Curry; he's still cooking:
https://theringer.com/steph-curry-fit-kevin-durant-warriors-nba-adjust-f2fcab7e1ce2#.xk6ij2lh7


Rehab/Performance

Bill Hartman with a well-written post on systemic interaction. In a few short paragraphs he effectively covers topics of motor control theory, degrees of freedom with respect to movement, and organization of training/movement parameters to elicit a desired training or rehab outcome.
http://www.billhartman.net/blog/padawan-lesson-systemic-interaction/
 

Rehabilitation, Restoration, and Reconditioning with Doug Kechijian
https://simplifaster.com/articles/rehabilitation-restoration-reconditioning-doug-kechijian/
 

Old article with gems from Charlie Weingroff's "How to Make a Monster" seminar at IFAST several years ago
http://zimoore.blogspot.com/2012/02/knowledge-bombs-from-charlie-weingroffs.html
 

A helpful nutrition infographic by Precision Nutrition for injury recovery:
http://www.precisionnutrition.com/nutrition-for-injury-recovery-infographic


A recent study published in the Orthopedic Journal of Sports Medicine suggests that superior labral tears in the shoulder that appear on MRIs are due to regular changes that naturally occur with aging. As many as 70% of the subjects in the study were asymptomatic despite the presence of SLAP tears in their MRIs. Food for thought for people thinking they need surgery and are making this decision mainly from imaging results.
Research: https://www.ncbi.nlm.nih.gov/pubmed/26779556
Summary: http://www.howardluksmd.com/shoulder-pain-2/mri-findings-in-people-with-no-pain/
 

Do you treat patients with vertigo? Check out new guidelines on benign paroxysmal positional vertigo.
http://www.medscape.com/viewarticle/876491
 

Tendon pain management by Tom Goom
1) Tendon load progression
2) Monitoring pain and load response
3) Psychosocial factors in tendinopathy
4) Intrinsic risk factors


Breathing

More from Bill Hartman.
http://www.billhartman.net/blog/hierarchies/
 

"Breathe" by Kyle Ruth of Training Think Tank
http://www.trainingthinktank.com/breathe/
 

Pain Science and/or Biomechanics

Resources for clinicians on how to incorporate pain science into their patient education.
Key Messages for Patient Education: 
https://www.facebook.com/photo.php?fbid=10158235412790304&set=a.10154213093350304.1073741827.634815303&type=3&theater


On Patient Self-Efficacy:
https://www.facebook.com/photo.php?fbid=10158234563250304&set=a.10154213093350304.1073741827.634815303&type=3&theater


More on Reconciling Pain with Biomechanics by Gregory Lehman
http://www.greglehman.ca/blog/2017/3/6/tissue-changes-and-pain-explaining-their-relevance
 

Biomechanics matter even when they don't. By Erik Meira
http://thesciencept.com/biomechanics-matter-even-when-they-dont/
 

Ten Target Concepts from Explain Pain Supercharged by David Butler & Lorimer Moseley
https://noijam.com/2017/03/03/supercharging-explain-pain/
 

Clinical decision making in running form interventions by Gregory Lehman. More pain-related and biomechanical considerations.
http://www.greglehman.ca/blog/2014/02/24/clinical-decision-making-in-running-form-interventions-implications-for-injury

 

Exercise

Considerations when deadlifting with a mixed grip by Dr. John Rusin
https://drjohnrusin.com/stop-deadlifting-with-a-mixed-grip/
 

Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. As of February 2003.
http://bjsm.bmj.com/content/37/1/6.info
Full Article: http://bjsm.bmj.com/content/bjsports/37/1/6.full.pdf
 

For all the runners! This is like an open-chained reactive neuromuscular training drill for the peroneals to control the descent of the first ray to the ground.
https://daveleyland.com/2017/03/08/a-simple-but-highly-effectiveperoneal-exercise/

 

Critical Thinking

From one of my favorite new bloggers/thinkers in the rehab world, Jason Eure. On logical fallacy, confirmation bias, and more.
http://www.physiologicalpt.com/physiological/2017/3/3/argument-and-the-ever-shifting-goalposts
 

Why facts don't change our minds. A little non-PT-related reading.
http://www.newyorker.com/magazine/2017/02/27/why-facts-dont-change-our-minds
 

2017 USAPL Spring Forward Championship - Gardiner, NY

Second meet is in the books! Overall I went 9 for 9, PR'ed on all 3 of my lifts and added 20 kg to my total from my first competition. I had a LOT of fun at this one which was at an amazing venue, had strong competitors across genders/weight classes and an energetic crowd as well. It was awesome to compete alongside my friends of the Catch22 NYC Dragon Boat Barbell Crew who made a strong showing both on the platform and as a cheering squad. Congratulations to Coach Sean of Murder of Crows Barbell Club and Yuechuan Sun for taking first and second place in the 74 kg class, and Dave J Woo for first place in the 105 and Best Overall Male Lifter with just monster performances. Much much thanks to Alfred Winghong Jong of The Strength Guys for coaching and schooling me to the game!!
_
Last but certainly not least is the woman in my life without whom I literally could not do this, my wife Maureen Lee! Thank you for being my biggest fan, healthy food chef, life coach, PR/marketing strategist and always my source of strength. She also compiled my lifts into this following video! Competing and hitting PRs is fun and all, but my deepest sense of happiness and gratitude from all this comes from your unconditional support, love and encouragement. I love you and thank you for keeping me on track mentally, physically and emotionally--I can't wait to lose my voice cheering for you at your dragon boat races this summer!!
_
S: 170 kg | B: 115.0 kg | D: 207.5 kg

Rocktape FMT Blades Course Review

This past weekend I attended Rocktape's FMT Blades course at the Brooklyn Athletic Club here in NYC. Rocktape has been around for quite some time now and has been steadily increasing the number of continuing education courses they offer beyond just taping, including a "movability" course,  a special populations course and even animal-focused therapy courses. I received virtually zero exposure to instrument-assisted soft tissue mobilization (IASTM) during my formal education, and had only come across it in the past as a portion of Dr. Erson Religoso's Eclectic Approach seminar. Having heard good things about Rocktape's series of continuing education courses, I was eager to dive in.

A main point regarding the mechanisms behind IASTM that was established early on was providing sensory input that would in turn help guide a desired motor output. Personally this was important for me as I believe the concepts behind manual therapy or soft tissue management systems should be as aligned with modern pain science as possible. In regards to mechanical versus neurological mechanisms, the former model appears to be receiving more scrutiny as far as the scientific literature is concerned. For example, clinically speaking I subscribe to the beliefs that there is poor inter-rater reliability behind the ability of clinicians to locate trigger points, that fascia cannot be physically deformed and changed without a tremendous amount of force and that soft-tissue adhesions can't be simply rubbed away. Therefore in order for me to responsibly incorporate IASTM into my practice, the primary reasoning behind its usage would be that it'd be influencing the nervous system to change neurological tone or to decrease the perception of threat which would then allow windows of opportunity for desired rehabilitative neuromuscular activities to then occur. 

The didactic portion of the course delved into a bit of the science surrounding pain, fascia and the physiology of mechanoreceptors which helped set the stage for the different techniques we would learn and employ with our instruments. Having no instruments of my own heading into the course other than Kelly Starrett's Mobility Star product, I opted for the course price of $550.00 which included an FMT Blades kit containing two instruments (the Mallet and the Mullet), emollient and alcohol wipes. This kit's retail price on the Rocktape website is $299.00, and if you already have your own set of tools you are given the option of a $250.00 price for taking only just the course. For a single-day course to include these tools, a roll of Rocktape and an unexpected bonus of lifetime discounts to their products, the price of $550.00 is probably one of the most competitive prices as far as IASTM continuing education courses go. Another big bonus for me was that it was a convenient 15 minute drive from my house, which is always nice for weekend courses.

The mallet.

The mallet.

The Mallet is made of surgical-grade stainless steel, weighs one pound, has four treatment surfaces and is engineered to offer six different types of comfortable grips. It is the more robust of the two tools and feels both comfortable and durable in my hands. A problem I've encountered with other tools I've used in the past was that their awkward shape never quite allowed me to get a comfortable grip for applying treatment. So it was nice to not have my hand cramp while using the Mallet.

 

The mullet, complete with bottle opener.

The mullet, complete with bottle opener.

The Mullet is the lighter of the two instruments weighing in at 0.4 lbs and is constructed of thermo-plastic polyamide. While lacking the versatility of different grips, angles and greater surface-edge size of its Mallet counterpart, it is more lightweight and portable. Also has a nifty can opener that is built in--no joke.

At this point I'm going to digress a little bit from the review to discuss my brief experience with the Graston Technique at the course. A knowledgable gentleman also attending the course who is a private-practice chiropractor sat next to me throughout the day and was my partner for most of the breakout activities. After some initial group ice-breakers, he informed me that he had been using the Graston Technique for many years in his practice, and I allowed him to perform his techniques upon me so that I could get a feel for the difference between Graston and the FMT Blades method. I've never taken a Graston course and can only speak upon it based on what my partner told me, but the force applied to my skin was much harder. After only 2 minutes of scraping to my right latissimus dorsi, I received the following skin response:

After only 2 minutes of receiving Graston to my right lat.

After only 2 minutes of receiving Graston to my right lat.

While not painful, I was surprised at the vascular response my skin produced from such a short period of scraping and I don't doubt that the epicenter of erythema would've easily developed into darker shades of petechiae. While he was explaining his methods, based on his verbiage I was under the impression that my partner subscribed to more of the mechanical-based approach to IASTM along with the neurological-based approach. This theme appeared to be consistent throughout the day as we partnered up for additional activities. Upon noticing my skin reaction and not desiring to be any more bruised, I kindly asked him to refrain from such pressure to which he also kindly obliged. For the record, we became friends throughout the course and he was a great partner to have. He freely shared his knowledge and I was grateful to learn from his clinical expertise in using IASTM despite our differences in treatment approaches.

The course also included some educational content on their taping philosophies and included exercises involving the combination of "taping & scraping". Several volunteers from the class received movement assessments in front of the room, received taping and/or IASTM and were subsequently reassessed. Out of all the course content I was probably the most critical of these case studies. The assessments and movement screens were basically abridged portions of SFMA top-tier tests and a couple of their breakdowns. Now, I understand that for the purpose of the course's objectives, it is not practical to perform entire SFMA breakouts in order to reveal the underlying root cause of pain or dysfunction. The course instructor also responsibly admitted this throughout the day. But when fundamental concepts like mobility versus stability and regional interdependence are continually emphasized throughout the course, the case studies and class demonstrations should illustrate those principles correctly. The SFMA is not required to take this course, but when a class consists of fitness and healthcare professionals from different educational backgrounds and disciplines, sometimes making a general conclusion off a small fraction of a top tier test can be a slippery slope towards misapplication of course concepts. It also creates dissonance between the the fuzzy areas that overlap between scopes of practice of different professionals. This is one area that I think would benefit from some change. All in all, when using the SFMA correctly and finding the correct direction to apply one's interventions, Rocktape's FMT Blades approach can definitely be effective.

At the day's end I was pleased with the course and would recommend this to health care professionals especially if you've never had educational exposure to this topic before. Knowledge of the SFMA and other Gray Cook principles of movement would greatly help flesh out some concepts and give more meaning within a treatment framework. I see myself incorporating the content into my daily practice, so it always feels good to walk away from these courses with some practical takeaways. It's always important to take into account the scientific evidence surrounding a certain kind of technique or approach, but remember that nothing is going to be always 100% scientifically justfiable and there are other factors to consider (think Sackett's model of evidence-based medicine). However, do make sure that it fits within the system or treatment framework that YOU employ, and do your due diligence when justifying your reasoning behind it.