More PRI Conversations
Okay, I know I probably talk about PRI a lot (mostly on social media). But I promise most of the time it’s because I’m responding to people who are engaging with my old blog post from 2017. An individual by the name of Chris took the time to thoughtfully & respectfully respond to my post and I thought it was appropriate to continue the conversation in an additional blog post.
Here is Chris’s unedited comment, for reference (warning, it’s long):
“For the people who haven't had success with PRI, it may not be the science, but merely the practitioner's inexperience. PRI is incredibly difficult to fully grasp and apply. I'm not a PT, but I have an education strongly rooted in biomechanics along with a fitness & coaching background and I've since become an LMT. I have taken six of the courses and I still haven't fully grasped how to apply it and how to decipher the different levels of compensation that I might be seeing. I understand the basic tenets and honestly, it all makes sense to me because you can see these patterns in people. That said, it does not work for everyone because humans are so diverse. But I will argue that if you find a very experienced practitioner, it's going to help the overwhelming majority of folks experiencing pain, etc. Further, some of the issues are more complex and that's why some of the basic PRI exercises may not be effective. The exercises you're seeing in Myokin, Respiration, Pelvis, etc. are just scratching the surface and are for the easier cases.
PRI is extremely integrative and there can be a whole host of other factors contributing to the problems. There may be something going on with the visual field or how the sensory information coming in from a person's occlusion or the feet. I can tell you that if you put me on a table right now and check my cervical ROM, I'll be locked up. However, if you put something between my right molars, my ROM of magically comes back. So, how does that happen? I went to the dentist to see if he could do something to improve my occlusion and two different dentists claim that they can't find any issues with the occlusion back there. I know that my SI joint pain is an entire systemic problem - it's not just my pelvis, diaphragm, etc. Unfortunately, I don't want to spend the $$$ to figure it all out because it's not debilitating and I'm not a professional athlete or something whose physical performance has such a direct impact on his livelihood.
At its very core, PRI can be simplified to two very important human functions - breathing and gait. The PRI concepts provide a deeper understanding in how air flow and pressure differences dictate and/or affect human movement and in particular, the ability for humans to function as a bipedal species. That's really what PRI is all about. So, many of the common postural distortions are the body's strategies for achieving these two fundamental aspects of human existence. Due to the asymmetries ranging from not just organ structure, but also the cortical motor neurons in the brain, most humans get lateralized to the right side, which corresponds to the right stance phase of gait. As a result, the body compensates in different ways depending on our habitual movement patterns and needs. This is why you'll see varying degrees of compensation depending on the individual.
What bought me into the tenets of PRI are its predictability with the different tests it uses and the fact that the anatomy really makes so much sense. One "A-Ha" moment came when I realized how rib position is so crucial to fixing scapular winging. You can assign someone all the push-up plus / serratus anterior activation exercises in the world, but if that rib cage is not positioned properly, you'll never correct it.
I could go on and on, but I don't think there's a more powerful system of rehab and therapy than the science of PRI. Will it work for everyone? No. But I do feel that when properly applied by an extremely experienced practitioner that understands how to integrate the other disciplines (optometry, dental, etc.), it will help 90% of people dealing with pain. That's a big statement, but for me, the science that they teach just makes too much sense. Is there a place for all other modalities? Absolutely. Humans are so complex that PRI won't fix all. For those that PRI won't fix per se, I think some of these other approaches can help with symptom management for sure. But I don't think there's a system better than PRI that both EXPLAINS and is able to address the actual root cause of different issues.
I would encourage you to take more courses and to go spend some time with experienced practitioners and see if your opinion might change.
One major criticism I have of PRI is the courses and their delivery. The courses are entertaining and I enjoy the presenters. However, I think they could be done in a far more straight forward approach than how they are delivered. The fact that I've taken six courses (96 hours) and still feel somewhat clueless as to how to apply it relative to my scope of practice as a personal trainer / massage therapist is a problem. They deliver the courses with too many metaphors and silly stuff instead of just laying out the information in plain English in a sense. Honestly, I've grasped a better understanding of PRI from Conor Harris and his YouTube stuff. His information is straight forward and it makes so much sense. So, that's my biggest knock on PRI. It could be taught in a more straight forward manner and maybe that's why you've struggled to buy-in.”
I’ve selected excerpts of Chris’s response to specifically respond to (his words in bold):
“For the people who haven't had success with PRI, it may not be the science, but merely the practitioner's inexperience. PRI is incredibly difficult to fully grasp and apply.”
I’m not really sure what to make of the statement, “It may not be the science” as a reason why someone may not experience pain relief or performance improvement from PRI. Regardless of whether or not people have success with PRI, science is science–PRI has made contentious claims and hasn’t supported these claims with evidence. “It may not be the science” isn’t really a relevant statement here because there is extremely poor evidence to begin with. And the burden of proof remains on PRI to provide higher quality evidence in support of their interventions and the mechanisms behind them.
Stating that someone may not be experienced enough to apply PRI successfully as a reason why someone doesn’t experience success raises a number of issues. Now, I don’t doubt that practitioner experience is important, and that there are differing levels of complexity to certain rehab approaches. But when highlighting the need for practitioner experience following a statement that casts doubt on the significance of/need for scientific evidence, this in effect is an attempt to absolve the need for evidence. Why should PRI be exempt from having scientific backing to it? Being “difficult to apply” and understand and then casting the burden to see success upon the practitioner isn’t a strong foundation to base a system upon.
I'm not a PT, but I have an education strongly rooted in biomechanics along with a fitness & coaching background and I've since become an LMT. I have taken six of the courses and I still haven't fully grasped how to apply it and how to decipher the different levels of compensation that I might be seeing.
__
I would encourage you to take more courses and to go spend some time with experienced practitioners and see if your opinion might change.
I appreciate this individual stating his educational and professional background which helps give some context to his beliefs and framing of PRI. I almost never talk about the details of my educational background other than mentioning that I’m a physical therapist but sometimes I do think it’s important to mention that a DPT’s educational background consists of much coursework over the course of 7 years surrounding anatomy, physiology, kinesiology, statistics, research, orthopedics, musculoskeletal rehabilitation, neuroscience and clinical experience working with patients in which these topics have much relevance.
When I took PRI’s Myokinematic Restoration, as my original blog/review stated, there were dozens of claims and topics that were inconsistent with everything I had learned in my educational and professional career at that point. I was open-minded to learning new things–I would never claim that I know everything, not even close–but I didn’t come to the conclusion of “This is too complex; I need to take more PRI courses so I can understand the deeper roots of everything.” If the basic foundational courses have such great complexity and make such unsubstantiated claims, why should clinicians be encouraged to take further higher level courses that build upon those shaky foundations? Doesn’t that sound backwards?
PRI is extremely integrative and there can be a whole host of other factors contributing to the problems. There may be something going on with the visual field or how the sensory information coming in from a person's occlusion or the feet. I can tell you that if you put me on a table right now and check my cervical ROM, I'll be locked up. However, if you put something between my right molars, my ROM of magically comes back. So, how does that happen? I went to the dentist to see if he could do something to improve my occlusion and two different dentists claim that they can't find any issues with the occlusion back there. I know that my SI joint pain is an entire systemic problem - it's not just my pelvis, diaphragm, etc. Unfortunately, I don't want to spend the $$$ to figure it all out because it's not debilitating and I'm not a professional athlete or something whose physical performance has such a direct impact on his livelihood.
Placebo, meaning response and confirmation bias are some helluva drugs.
Chris’s experience here illustrates another one of my hard criticisms of PRI. There is a large emphasis on highlighting complex, multi-regional patterns of biomechanical compensations that require intervention or are alleged to be the source of some physical, undesired dysfunction. This causes individuals who buy into the system—both practitioners and clients alike—to be hypervigilant about very specific patterns of movement and function involving the pelvis, diaphragm, adductors, molars, sphenoids, ribcage, specific portions of the abdominal wall, scapulae, mandible, specific fibers of gluteal muscles, maxilla, the tongue, sacroiliac joint, etc.
They are led to believe that something is wrong when that may not necessarily be the case at all, as there are many naturally occurring asymmetries in the body that aren’t inherently pathological like PRI makes them out to be. Many biomechanical presentations that were once thought to be pathological (i.e. scapular dyskinesis) are now not seen as such due to emerging evidence that PRI conveniently never addresses nor seems to incorporate into their teachings. I can’t help but think that PRI has a vested interest in the way they are already doing things and have taught for over a decade, and that it’d require too much of a paradigm shift to update their ways of thinking to be more aligned with current evidence.
But that’s the nature of science—constantly auditing what we think we know as new evidence emerges so that we can update our previous modes of thinking on a journey to be less and less wrong over time.
Chris’s experience with his molars is also another reason why I think it’s important to have an evidence-informed narrative backing the reason for a treatment. There can be a myriad number of reasons why biting on something can free up range of motion temporarily. It may not necessarily be because of some occlusion-related issue. You can probably do some jumping jacks, push-ups and bodyweight shrugs and cervical range of motion would similarly increase temporarily. Additionally, seeking qualified healthcare professionals such as dentists to evaluate dental occlusion (which was a good move) and not finding any issues should cast some doubt onto the diagnosis/mechanism of dysfunctional mandibular biomechanics causing transient cervical ROM deficits. Where is the skepticism for PRI in their diagnosis for this issue?
At its very core, PRI can be simplified to two very important human functions - breathing and gait. The PRI concepts provide a deeper understanding in how air flow and pressure differences dictate and/or affect human movement and in particular, the ability for humans to function as a bipedal species. That's really what PRI is all about. So, many of the common postural distortions are the body's strategies for achieving these two fundamental aspects of human existence. Due to the asymmetries ranging from not just organ structure, but also the cortical motor neurons in the brain, most humans get lateralized to the right side, which corresponds to the right stance phase of gait. As a result, the body compensates in different ways depending on our habitual movement patterns and needs. This is why you'll see varying degrees of compensation depending on the individual.
I’m not upset at this individual for believing this, I’m upset at Ron Hruska and the clinicians he has educated over the years that perpetuate these beliefs without citing evidence for these very, very bold claims, and I’m upset at the American Physical Therapy Association at the national level and state chapters for allowing continuing education courses like PRI to teach these things to people. Thoughts and ideas can pick up popularity over long periods of time, despite lack of veracity. With the advancement of technology and social media, these popular, unsubstantiated beliefs spread like wildfire and make their way to influential people in the rehab and fitness world. Strength coaches and personal trainers then adopt and teach these very unsubstantiated beliefs and questionable systems and it becomes embedded in fitness and wellness culture. We PTs, collectively as a profession, are largely to blame because we allow this to happen.
What bought me into the tenets of PRI are its predictability with the different tests it uses and the fact that the anatomy really makes so much sense. One "A-Ha" moment came when I realized how rib position is so crucial to fixing scapular winging. You can assign someone all the push-up plus / serratus anterior activation exercises in the world, but if that rib cage is not positioned properly, you'll never correct it.
I could go on and on, but I don't think there's a more powerful system of rehab and therapy than the science of PRI. Will it work for everyone? No. But I do feel that when properly applied by an extremely experienced practitioner that understands how to integrate the other disciplines (optometry, dental, etc.), it will help 90% of people dealing with pain. That's a big statement, but for me, the science that they teach just makes too much sense.
“The intensity of the conviction that a hypothesis is true has no bearing on whether it is true or not.” -Peter Medawar
Is there a place for all other modalities? Absolutely. Humans are so complex that PRI won't fix all. For those that PRI won't fix per se, I think some of these other approaches can help with symptom management for sure.
I’m happy that we stand in agreement together on this topic.
“One major criticism I have of PRI is the courses and their delivery. The courses are entertaining and I enjoy the presenters. However, I think they could be done in a far more straight forward [sic] approach than how they are delivered. The fact that I've taken six courses (96 hours) and still feel somewhat clueless as to how to apply it relative to my scope of practice as a personal trainer / massage therapist is a problem.”
This is a glaring issue to me. I don’t think it’s you. It’s just smoke and mirrors.