I have a patient who had a Standing Reach Test to their ankles.  I instructed them to protrude their jaw forward and to the right while placing a pen between their teeth on the right side.  I re-checked their Standing Reach Test and they were able to get to the floor.  Could you please help me to understand this? 

By placing your mandible forward and to the right and while deactivating the left temporalis and activating the right medial pterygoid and left lateral pterygoid to externally rotate and flex the right temporal bone in a state of inhalation on the right, allows the sphenoid to rest in a more symmetrical stable and secure neutral position: allowing the entire compensatory extensor tone of the body to decrease.  Without a neutral sphenoid, cervical and thoracic flexion is difficult. 

I was wondering what PRI’s opinion was in regards to mattresses.  Is it better to have a hard or soft mattress? I have heard mixed opinions on what is considered good support for a mattress. Some say a firm bed is more supportive than one that is too soft, while others will say a firm bed offers no support at all since there is nothing conforming to your spine.  Can you please advise what aspects one should look for when choosing a mattress? Theres so many options now days…firm, soft, pillow top, plush top, memory foams, etc. Are there any in particular that PRI recommends?

Start with integrated support.  Support for your body depends on coil count, coil type, and coil connection.  More coils equal more support.  Beds of same size will contain different amount of coils, depending on the gauge of the coil and the quality of the mattress.  You should look for mattresses with these minimum quantities of coils: at least 450 in a king-size mattress, 375 in a queen-size mattress, and 300 coils in a double bed.  Remember the more the coils the more overall support. Then consider the shape of the coils.  Hourglass coils, which provide more resistance as pressure increases, are suitable for those who are not too heavy and want more softness out of their mattress.  Continuous coil mattresses are made from a single piece of wire that is shaped to form a system of coils and are not recommended because of wire patterning over time with consistent imprinting.  This is why I recommend switching sides with your partner if you sleep with one, or rotating the mattresses top to bottom at least quarterly. Open-ended or pocket-spring coils are recommended because they function as an integrated system with separate connections made out of wire or fabric pockets to allow each coil to work independently in responding to weight and pressure.

Next, immediately look at the warranty.  Most warranties for brand name mattresses are 10 or more years. The more expensive the mattress the longer the warranty tends to be.  Warranties are pro-rated, meaning that if a 10 year warranty mattress fails in the 8th year you will get 20% of the purchase price applied to your next mattress. I recommend purchasing mattresses with 12 to 15 year warranties if you can afford to do so, even if you plan on purchasing a new one in 10 years.  The average person is using a mattress that is more than likely 10 to 15 years old.

The next consideration should be who is going to use the mattress. At least 12% of married couples do not sleep in the same bed, and a significant percentage of the other couples experience problems sleeping in a shared bed. Buying a larger bed does not necessarily help.  Buying two single beds may help get a good night sleep.  As baby-boomers grow older many are purchasing a normal couple-sized bed, a queen or king, and also a transition bed or a single bed with an appropriate mattress. None-the-less both partners need to lie side by side in the middle of the mattress, on their backs, without their trochanters or hips falling below the edge of the bed, if they plan on using the same mattress at the same time.

Once you know the integrated support system, the warranty and the size and number of beds you need, then you need to consider the firmness or “feel” of the mattress.  This is the comfort layer.  It is the layer that lies between you and the core or coil support.  Unfortunately, many make the mistake of selecting a mattress on this comfort layer only.  It is however, important to recognize that this is the layer that accommodates your zone of apposition needed for breathing and allows for passive tri-planar integration for healthy respiration when on your side or back.  It also is the layer that dictates cervical pillow needs and contour types.  Therefore, the comfort or top layer should be the fourth consideration before you consider price.  High end mattresses will fill their comfort layers with down feathers, wool, silk, premium foam, etc.  Lower end mattresses will construct the comfort layer of lower grade foam, coconut fibers, and reclaimed cotton fibers.  These break down sooner and can become lumpy.  You don’t need to spend more for luxurious materials like silk and cashmere that may be used in small proportions to market the mattress as a high-end mattress.  Pillow-top mattresses are usually a two-to-three inch top sewn on top of a mattress.  Your euro-top mattresses are similar to pillow-tops but are more tightly contained, which makes them less likely to shift and reduce edge sturdiness.  A mattress should give full support all the way to the edge and the edge should feel just as firm as the center, if not firmer.
This edge provides the support necessary to keep your pelvis neutral and your hip flexors and back extensors relaxed every time you sit to “get” into bed or “get” out of bed.  The edge of the bed is the repositioning source of the mattress and the integrated coiled support of the mattress offers passive support for proper ventilatory retraining.  Therefore this is the postural rest-oration step of mattress selection.  Because of firmness descriptions varying from manufacturer to manufacturer, I recommend purchasing the mattress that is most comfortable to you (or you and your partner). A “medium-firm” feel is usually the one most selected but also the one I would recommend for active feed-forward appropriate rib kinematics during downright positional rest.

Finally the price.  You will need to sleep on something 365 nights a year for an average of 30,660 hours of rest in 12 years. You don’t want price to override the above sequenced considerations. Buy a high-end mattress if possible!  If you are looking for a mattress for a guest room that is only used 3 to 4 times a year, there is no reason to buy a high-end mattress.  I would remain skeptical of any queen sized mattress priced below $800, even if is marked 20% down.  You must not look at prices first.  The value lies in the construction and the qualities outlined above.  A $2000 mattress will cost you 6 cents an hour or 40 cents a night if you take in consideration the above example of a 12 year warranted mattress.  You probably spend more a day parking your car per hour than your body, if you buy a mattress without taking these considerations seriously.

Other recommendations:  Stay away from foam, water, futon, latex and air mattresses.  I cannot find any reason to discuss or compare them to coil or inner-spring mattresses.  And remember the bed market is a very competitive sector of the economy.  The inner-spring market has the three “S” brands: not sacrum, sternum or sphenoid; Simmons, Sealy, and Serta.  Each has a number of mattress lines from the basic to the high end.  And there are a number of other brands that offer very good mattresses in this category, so lack of selection should not be a problem.  I have found that the specialty mattresses such as Tempur-Pedic (memory foam) and Select Comfort (adjustable air) are greatly appreciated by those who like them and want a mattress to conform to them, and greatly disappoint those who purchase them and find that they don’t prepare them for daytime activity because of poor re-positioning during normal healthy nocturnal active subconscious movement.  One more suggestion; after purchasing your new mattress, take a permanent marker and write the date on the lower end side of the mattress, so you know when you purchased it and how many years your spine was supported by it.

If you have a “roto-scoliosis” overlying a Left AIC, and you respect the Left AIC, wouldn’t you expect a right Type I and left Type III (I’d almost expect an exaggerated Type 1 and III if I imagine how the spine should look then place those scapulae on top of the ribs)?

Yes you would!  Your typical non-patho compensatory scoliosis is the patient that has a right thoracic curve, usually resulting in a right Type I and left Type III scapula position, however, there are so many possibilities with respect to the “patho” or “non-patho” scoliotic patient. 

There is some degree of rotation in all of these patients through the spine.  The degree of thoracic concavity and convexity and the location of the curve (apex at T4, T8, etc) all can have an impact on the scapula as well as the compensatory use of levator scapula, upper traps, SCM, pecs and rhomboids. 

I am still having difficulty with getting good results using PRI with certain patients.  One of them is HNP (herniated nucleus pulposus) patients who have pain with lumbar/thoracic flexion.

I actually work with two therapists who use the Mckenzie approach.  We discussed how PRI techniques can apply to HNP patients.  That’s when I learned about an email you wrote, “Integrating Mckenzie approach and PRI” (found in recent email archives).  I read your response over and over.  
I am kind of now committed not to use extension exercises because I do not want to lose ZOA like you mentioned in the response.  Now I have a 17 year old patient who has lumbar HNP.  I tried several exercises you recommended in your email but I still have difficulty with getting good results.  He is now considering getting surgery which I really want him to avoid.  By the way, a therapist in the past used the Mckenzie approach with him and he mentioned that he had some good results.  In the past, I have tried PRI to other HNP patients and the result is 50/50 (I actually had incredibly great results with a very severe patient).  So I still feel I need some advice on HNP patients.  Would you ever recommend using lumbar extension exercises to some patients (which honestly sometimes I am tempted to do so since some patients have relief doing extension exercises)?  I would really appreciate your clarification.

Every patient with HNP is different, as you know.  A 17 y/o who has a lumbar HNP, doesn’t automatically make him a “PRI patient”, a “McKenzie patient”, or a “surgical patient”.  What’s his overall system demeanor…is he high strung, anxious, relaxed, limited in SLR, limited in the frontal plane, acute or chronic with symptoms, radiculary impacted, etc…?  If they can’t achieve and maintain ZOA, during extension of the back, they probably are guarding, sympathetically driven and sagittaly inclined…all which forces discs posteriorly.  So, I am not opposed to “extension”…provided the patient can relax during the return to “flexion”.  Too much emphasis is often placed on the “sagittal” issue when the reality of imbalanced hip flexors (transverse plane) and paraspinals, multifidus, quadratus lumborum, latissimus, etc (frontal plane) are a greater issue because of torsional tri-planar patterns (usually Left AIC). 

Regardless if extension, with or without a concomitant ZOA, is first or not…whatever reduces radicular symptoms helps the patient recognize a “change”.  Can this change then be incorporated into a safe neuro biomechanical program?

The etiology or cause of HNP has to be changed regardless of what approach you use to ‘treat symptoms’.  In this case, I truly believe a 17 y/o will not recover only from the use of ‘extension-based’ activity.  The hip flexors and diaphragm crura need assistance from transverse plane oriented abdominals.  Otherwise those lumbar discs are going posterior because of young, strong (17 y/o) anterior longitudinal ligament and high joint intradiscal compression with or without surgery he needs thoracic-lumbar-pelvic stabilization.  The evidence-based literature will tell you passive guidance and lumbar traction is not an effective treatment program for HNP.  What needs to be inhibited on this 17 y/o?  A pattern. 

I am inquiring about a patient of mine that you have seen.  I believe I understand your reasoning for keeping her symmetrical below her neck and then adding left pterygoid activity. Although, you can still see the left rib flare and she still came in with decreased right HG IR. I instructed her in the Rest Position handout occasionally throughout the day to breathe. I gave her a clothespin and had her gently bite down a few times. This restored her and helped her see what left pterygoid activity does. Is it okay for her to continue with the clothespin? Would it be okay to have her orthodontist build up the left side of her resting splint 1-2mm?  I am also wondering about the sequencing of your exercises (jaw exercises first vs. lower extremity exercises).  How did you decide that she was ready for a symmetrical program below the neck since I am still seeing some asymmetry?  Was it just because her left glute med/hamstring and right glute max are stronger now?

The clothespin is keeping her autonomically alive, if you will, on the left side, occasionally she could do this.  I probably wouldn’t build up her left side of her splint yet.  I really believe she is in a body on head neuromotor pattern and needs better guidance from her OA and AA joints, cranium, vestibular and neck area.  She did well here with her updated HEP.  Please keep her vision parallel with the floor…in other words, don’t encourage her to look down so much with single leg work, holding her baby, getting in and out of a chair, etc.  Yes, she is sufficiently strong at her glutes, but still needs more left hip shift or COG vestibular balance on the left.  Therefore, I hit the adductors as a group hard on the left. 

I have a 10-year old soccer player and swimmer who suffers from bilateral hamstring bursitis at her ischial tuberosity.  She uses her hamstrings for EVERYTHING.  She holds a lot of tension in her hamstrings constantly and also her low back, however, she can squat easily to the floor.  What is the simplest way to shut down her hamstrings?

If your 10-year old soccer player has ischial tendonitis and hamstrings always feel tight and she can easily squat she probably needs glutes.  We don’t see very many swimmers with good, balanced glutes.  She also may need to learn how to walk with good supporting shoes – good heel cups, sufficient arch, etc and tied shoes when she walks.

Simplest way for a 10-year old to turn on glutes without back or extreme hamstring, while engaging abs and glutes…hula hoop…both feet at first and them one leg.  Bicycling in low gears and PRI Retro Stairs ascents and descents would also be good!

I was wondering if you guys have any information or suggestions on PRI treatment for patients with Parkinson’s?

The main focus from a PRI approach is to focus on neutrality.  You are not going to be able to do “typical” PRI work with this patient but you can work on achieving neutrality.  Once they are neutral, you would also work on reciprocal function during gait.  Dynamic reciprocal activity would be our major focus when working with someone with Parkinson’s Disease. 

What are your recommendations on kids doing gymnastics and dancers and getting stretched out to no end?  My kids are in gymnastics and I want to talk with their coach about not setting them up for issues but not sure how to approach it.  My kids are 9 and 6 and they work on the splitz all the time which stretches their capsules.  How do I create balance for them or is that possible if they stay in the sport?

I would incorporate any of the PRI single leg squat-balance activities.  Slow sit to stand and stand to sit single leg work, Retro Stairs (both ascents and descents), 90-90s or single leg paraspinal releases, etc.  They need to be mindful of their glutes and hamstrings and maintain frontal plane control on one leg while not participating in the sport of their choice.  This activity can be worked on while not in practice or competition. 

On making the Gelb Splint, would you make the left side a little thicker than on the right? I know when putting arch supports in we may go a little bigger on the right. Does this correlation make sense?

We suggest that you do not make the left side thicker than the right. The correlation does make sense but the Gelb with more left height will torque the maxilla since there is not anterior guidance. We would not routinely build up left side on maxillary splints or mandibular flat plane splints.

In golf it is considered important to be able to shift your weight to your left side as you transition from your back swing into your down swing.  Most golfers do this by shifting their left hip over their left foot while inverting their left ankle.  As I understand the role of the left evertors effect on the left adductor (facilitation of the adductor through peroneal activity) the above described movement of golfers (inverting their ankle as they attempt to shift their weight to the left) would essentially diminish ones ability to create a stable left side (due to inhibition of left adductors) in order to promote the required L AF rotation for swing path consistency.  If I am in the ball park on this what would you recommend for golfers in order to diminish the negative effect of ankle inversion?  Would it be simply to try to maintain an everted ankle at least through ball contact?  Or, is it to have the golfer be as neutral as one can be in normal activities and simply allow this inhibiting motion of the ankle to occur as it does in the golf swing?

You are correct in stating that during the down swing, it is important for a right-handed golfer to transfer their weight to the left leg. In my experience, golfers demonstrate too much frontal plane activity during the golf swing, and little AF rotation. During the downswing, it is difficult for most right-handed golfers to achieve adequate left AF IR during the downswing. Although frontal plane PRI activities are still important, I would focus on left AF IR activities when developing a treatment program.

In regards to ankle mobility, the Impingement and Instability course manual actually discusses the importance of the right evertors to inhibit the right adductors and facilitate left adductor activity. Therefore, I would actually be more concerned in the activity of the right foot/ankle and its effect on left adductor facilitation and promoting left AF rotation.

In my experience as a golfer and PT, I would focus on providing a home exercise program to facilitate a neutral pelvis and allow the transitions from normal activities to occur naturally with the golf swing as the patient improves lumbopelvic position and strength. One suggestion to help facilitate right eversion during daily activities and during the golf swing would be to place a scaphoid pad in the right arch to encourage proprioceptive activity and facilitate calcaneal eversion, thus encouraging left adductor activation. 

I am cautious when attempting to change the golf swing. If you have seen the movie Tin Cup, you know that when a golfer “thinks too much” about the swing, they will start to shank the ball and get rather frustrated. I have learned that it is sometimes best to facilitate a neutral pelvis and improve lumbopelvic strength with a HEP and then occasionally the patient’s golf swing mechanics will adjust.

I recently took the Cervical-Cranio-Mandibular Restoration course.  I had one of my patients ask her dentist about her bite and this is the information she gave me:

• Posterior: class III left side cross bite
• Anterior: class I

Could you explain what this mean in terms of PRI tretment?

Your patient basically has a normal anterior bite but a small upper arch on the left or a cross bite that is positioning her lower teeth on the left forward, weakening her left lateral pterygoid and loading her right TMJ for pivotal chewing. She’ll probably need a splint to open her right bite and align her cranium or orthodontistry to correct her left malocclusion before a good PRI program will relieve any symptoms at the cervical-cranio-mandibular complex. If she has no symptoms, I would treat her by restoring right BC issues only.

Why is a grade of 0 attributed to just “obturator” weakness…..wouldn’t it be weakness of all external rotators?  And, is that obturator internus and obturator externus or just obturator internus?  “Glutes” are listed as opposition muscle to the AIC, do you mean glute max or glute max and glute med?

The obturator internus and externus have the best mechanical advantage of pulling the acetabulum “onto the femur” and therefore if the patient cannot “raise lower ankle off the mat” the ability to approximate the A to F or F to A is poor. This poor proprioceptive and mechanical ability limits frontal and transverse function. The glutes (gluteus maximus AND gluteus medius) are opposition muscle to the AIC.