I am wondering what the Institute’s experience or thoughts are regarding maxillary expansion appliances in young kids. Would you recommend that they be seen by a PT prior to being fit with the appliances to make sure there are no alignment issues that need to be addressed with PRI treatment/exercises? And have you noticed improvement in headaches, neck pain following expansion?

Maxillary (palate) expanders in young kids have been used for years. In fact, this has primarily been a pediatric concept. When you have an interdisciplinary integrated team that can help monitor palatal expansion’s (i.e. cranial flexion) influence on the postural system, objective feedback from a PRI therapist can help guide and direct palatal expansion effort and success. If a child (or adult) is unable to achieve cranial flexion with PRI non-manual and manual techniques, and has a high/narrow palate, a palate expander could be helpful. Recently, dentists are using more ALF’s as dynamic palatal expanders vs. the “screw-type” palatal expansion orthosis, which is exciting for people like us because the lightwire allows more triplanar cranial movement. Usually, permanent teeth are required to stabilize these types of appliances, so you are probably looking at an age around 8 years old before these would be effective (but that age can vary with each child).

The reason we include a discussion on left ischial tendonitis and not right is because right ischial tendonitis is often ‘cleaned up’ or treated with a conventional myokinematic approach to the treatment of the Left AIC or PEC pattern.  One would start with “pulling” the anteriorly rotated pelvis back to neutral with left hamstring engagement (90-90 Supported Hip Lift with Hemibridge) then proceed with right glute max activity to “shift” the pelvis to the left and “rotate” the pelvis into left AF IR and right AF ER, therefore, reducing strain on the contracting, shortened right hamstring and the proximal attachment of the hamstring on the right ischial seat. 

So in essence you would treat the right ischial tendonitis issue by using the myokinematic hierarchy of lumbo-pelvic-femoral control for the Left AIC patient that is outlined and covered in the Myokinematic Restoration class.  Remember under every PEC pattern there is a Left AIC pattern, so even if your patient had right ischial tendonitis and had limited SLR on adduction levels bilaterally, I would start with the above recommendations.

The left ischial tendonitis patient will need more concomitant cooperation from the right glute max and left medial adductor and left quadricep during left heel strike and push off, to reduce left hamstring strain.

What is the reasoning for the jaw moving forward and to the left in the ‘Supine Active Sacro-Sphenoid Flexion’ technique and forward and to the right in the ‘Active Left Lateral Pterygoid in Protrusion’ technique?

Many of our patients have cranial base function oriented to the right secondary to the human spinal pattern often seen in the human right upper brachium and cranium (Right BC and Right TMCC patterns).  These patterns demand on the right lateral pterygoid (mandible often seen oriented to the left) and overdeveloped right sternocleidomastoid (head and neck often seen slightly side-bent to the left and turned to the left) can be reduced by activating the left lateral pterygoid.  The left lateral pterygoid assists in rotating the sphenoid or cranium to the left through its attachment on the lateral pterygoid plate of the sphenoid, and the base of the skull and upper cervical spine to the left, through lateral movement of the mandible to the right. 

Movement of the mandible to the right promotes good left lateral pterygoid function for meaningful chewing on the right with a balanced forward condyle to fossa relationship on the left during the actual downward power stroke.  Movement of the jaw to the right is, therefore, promoted which is so often lost on patients who are very active on their right side when they chew.  Right sided chewers over-activate their right lateral pterygoids immediately preceding opening and at the end of the downward power stroke on the right, by moving their mandible to the left after each power stroke.  Alternative chewing on both the left and right, is advisable as is keeping lateral pterygoid function balanced, by reducing right neck activity through left lateral pterygoid non-chewing function during the day.  The ‘Active Left Lateral Pterygoid in Protrusion’ is one way to keep balanced horizontal movement during mastication and the right cervical muscles relaxed because of the left lateral pterygoid indirect action on moving the cranium (sphenoid) and occipital base (OA/AA) to the left.

Because of the direct attachment of the stylohyoid, styloglossus and stylopharyngeus on the styloid process, moving the mandible to the left “pulls” the right temporal bone into external rotation and flexion, thus reducing intercranial torsion, and intraoral cants associated with the Right Temporal Mandibular Cervical Cranial (TMCC) pattern.  This technique reduces hemi-extension of the cranium, restores symmetrical cranial respiratory function and provides a complete base for the tongue to function without compensatory glossus activity.  By moving the mandible to the left, the hyoid, dorsal lateral tongue and pharyngeal thyroid cartilage move also to the left, promoting alignment of the airway and pharynx of the Right TMCC patient.

During the PRT testing process, Ron was saying he doesn’t particularly like the posterior pelvic tilt cue…. I was wondering what his rationale is and how he prefers to cue it….

In the past when I asked patients to do a posterior pelvic tilt, I asked them to tilt their pelvis posteriorly, in essence, without ever asking them to inhibit specific muscle to do so.  It usually ended up with them focusing on abs and back extensors that would tense up. Or they would stiffen their back in attempting to do so, or they would hold their breath, or they would press their feet on the floor while in a supine hooklying position, or press their feet in the wall in a 90-90 position. Or they would do something else that interfered with them “pulling” their pelvis back with hamstrings. The abdominal rectus is a posterior pelvic tilt killer. So now I ask them to move their knees forward. I wish everyone would remember that the only way you can do an effective pelvic tilt is with the “knees going forward with feet planted.”  If the knees do not go forward in attempting a pelvic tilt, you are tilting with abs that are braced or being activated with concomitant hip flexor and back extensor activity, minimizing an effective posterior pelvic tilt with hamstrings, glutes and abdominals that should be transverse plane oriented, not sagittal oriented. An effective posterior pelvic tilt requires a gluteus maximus to externally rotate an acetabulum on a femur, not just extend an acetabulum on a femur. Thank you so much for the question!  -Ron

I remember in one the courses that they discussed why discs are more likely to herniate posteriorly and I’m having trouble puzzling it out now. It seems like if the spine is tonically extended and the diaphragm becomes a postural stabilizer, that the anterior spinal ligaments would be working harder to compensate. So why is it that the posterior spinal ligaments are weaker and more prone to herniations?

Thanks for your question about disc pathomechanics and the tendancy for discs to herniate posteriorly.  You correctly mentioned the muscle tone in the L AIC pattern directing the spine into a state of spinal extension and the altered role of the diaphragm as a postural stabilizer of the spine (pulling it forward into extension) in this position.  Your question then asked about the contributing influence of the anterior vs posterior spinal ligaments in this extended position without discussing the destructive forces being directed into the annulus fibrosis portion of the disc.  This discussion would help you better understand the resulting disc pathologies as the nucleus pulposis herniates through the compromised peripheral support of the annulus fibrosis regardless of the tautness or laxity of the spinal ligaments.
When the muscle tone from the AIC pattern directs the pelvis forward into flexion and the lumbar spine backward into spinal extension, the compressive forces between the vertebral bodies is greatest at the posterior aspect of the disc.  This posterior compression is further exacerbated by the compressive influence of spinal torsion forces present in the discs as the upper lumbar spine and lower thoracic spine counter rotate back to the left because of the right oriented sacral and lower lumbar spine position in the L AIC pattern.  These sagittal and transverse compressive forces lead to posterior disc dehydration, weakening, tearing and an overall compromise to the posterior aspect of the annulus fibrosis.  The over-compressed and weakened posterior disc gives way to the wide variety of posterior bulges, posterior protrusions, posterior extrusions, etc as the nucleus pulposis is more easily forced through the weaker posterior annulus fibrosis as compared to the anterior annulus fibrosis, which rarely allows the nucleus to herniate anteriorly.
PRI’s approach to inhibiting extension muscle tone and negating the torsional influence of left vs right dystonia with breathing techniques does 3 powerful things to promote healthy disc tissue and function: 1) decompresses the posterior disc as the abdominals are used during exhalation to flex a hyperextended spine toward neutrality 2) relieves the torsional compression forces on the discs as left vs right muscle tone is balanced and the spine is rotated back to neutral and 3) allows the diaphragm’s crura to pull vertically on the lumbar spine (instead of forward into more extension) which decompress the discs upon inhalation.  This happens as the central tendon lowers during inhalation and the vertically positioned crura pull upwardly against the opposition of the properly positioned abdominal wall when the diaphragm and rib cage have been drawn down into a neutral spine state called Zone of Apposition.  This approach allows decompressed tri-planar movement across the previously restricted lumbar spine with ample support from the diaphragm, abdominal wall and anti-gravity postural muscles.
-James Anderson

When would it be appropriate to consider using the PowerLung with a patient?

I use the ‘power lung’ when I feel the diaphragm needs strengthening. In other words, the patient has a neutral brachial wall or chain and is capable of expanding but the power needed from the diaphragm is still poor.  I also use it when conscious cycling between inhalation and exhalation becomes more inhalation driven because of poor inhalation power and more accessory inhalation activity, that therefore limits comfortable exhalation and reduces ZOA.  Sometimes good powerful inhalation will diminish accessory inhalation demands and improve ph balance and drop off the hyperinflation tendencies.  However there is nothing like flexed thoracic exhalation.  I usually encourage power lung activity after or during the latter stage of the PRI exercise session.  With our visual patients I go at it fairly quickly and intensely to generate thoracic and diaphragm references so that the vision process doesn’t have a physical postural demand placed on it as much.

– Ron Hruska

On occasion, I will have some patients that cannot improve their glute strength. They typically are neutral and can find and feel the glute, but muscle testing reveals continued weakness and femurs remain internally oriented. I make sure they are getting eversion and have used orthotics for many. Often their add lift scores are not improving beyond 2 or 3. Any thoughts?

This is a great question and 3 things come to mind:

1) They are “Frontal Plane Challenged”: Abdominals are not integrating with adductors (the right adductor and abdominal wall are too strong/active and need to be inhibited, while the left adductor and left abdominal wall are weak or inactive). If the patient continues to be limited with frontal plane integration, there could be a descending influence possibly indicating the need for interdisciplinary integration.

2) They lack reciprocal upper and lower rotation, and likely do fine with counter-clockwise rotation, but usually have poor reciprocal clockwise rotation. The new walking stick program discussed in the Pelvis Restoration course (which will also be on our new exercise CD’s coming out soon) would be an excellent program to perform with an individual lacking reciprocal upper and lower rotation.

3) It is likely an AF (acetabular-femoral) problem, not a FA (femoral-acetabular) problem. FA rotation increases glute strength, but if this has been addressed and they still have weak glutes, then they are having trouble keeping AF position and strength. I would recommend reaching, flexion, squatting activities for improving AF position and strength.

Ron Hruska, MPA, PT

In the last course I was in, when the speaker did before and after repeats of the Hruska Adduction Lift Test, I saw a significant compensation when going from level 1 to 2 and then 2 to a level 3.  In other words, he would give someone a score of 3 or more after repositioning or applying a certain exercise, yet I would still observe them roll their pelvis back or trunk forward when attempting to lift from their original level 1 to 2.  Basically, I wouldn’t see much improvement from before to after.  Are we looking more at degree in which they need to compensate?  Example….did they not need to roll their pelvis back as far as the first time?  Where he would have given a score of 3 or 4, I still would have seen them at no more than a level 1.

The Hruska Adduction Lift Test allows for a small amount of pelvic and torso associated movement, but it should not be excessive.  I’ve never seen the full home study course videos but I was the one doing the testing, so the best I can do is just share my thoughts and guidelines for test scoring.  If they’ve moved out of left AF IR during level 2 testing into a position at the hips and pelvis that more represents left AF ER, then obviously they have compensated much more than they should have.  We want to watch their movements closely and help them coordinate the correct sequence of movements without very much compensation.  Having said so, we have to be a little bit flexible or we may never allow anybody to score past a 0 or a 1.  I like your eye for detail and specificity, but know that a little bit of shifting or rotating may need to be allowed in order to see how how well they can integrate the progressive steps of the test.  Whatever you do, be consistent and try to see in each step you test the appropriate phase of the gait cycle.  I hope some of these thoughts are helpful.

– James Anderson, MPT, PRC

In the Postural Respiration manual on page 50, “Considering BC test reasoning”, on the column titled: Right Scapula it has a bullet that says “resting in a protracted state (Rib hump) – if in a retracted state, indicative of compensation from right subclavius”.  What does it mean by compensation from subclavius and under what circumstances? 

The Right scapula has muscles specifically designed to retract it.  The primary muscles of retraction would be the posteriorly positioned middle and lower trapezius.  Occasionally the right subclavius (because of its attachment sites) can begin to assist in scapular retraction even though it is on the front of the body.  As the scapula moves forward the right mid and lower trapezius becomes mechanically disadvantaged and the subclavius becomes more powerfully positioned as a scapular retractor because of position.

So as the clavicle move forward the muscle attempts to retract it.  This can become even more significant in superior T-4 patients as the upper ribs elevate and bump up against the clavicle.

I don’t understand why the left hamstring is lengthened and the Straight Leg Raise test is limited on the left.  Doesn’t the lengthened hamstring give more leverage to the hip flexors?

The left hamstring is lengthened because the left ischial seat is elevated due to forward rotation of the left innominate.  For example, you could rotate both innominates forward if you were attempting to bend over and touch your toes.  When the left innominate rotates forward without the right and only the left Ischial seat is raised (like the toe-touch example) the hamstring on the left is lengthened but the right is not.  This position is present in those individuals with a dominant Left AIC pattern.  Now imagine this person is lying on their back and you compare the right straight leg raise to the left.  On the right (the side in which the innominate is NOT forwardly rotated) the straight leg raise should be greater because the right ischial seat is not elevated and the hamstring has not been lengthened already.  On the left where the hamstring is already lengthened due to the raised ischial seat the straight leg raise would be less.  If it is symmetrical or greater on the left then you have real trouble because now the individual has over-stretched an already lengthened left hamstring.

The TMCC pattern says the sphenoid is in right rotation and that we want to promote left sphenoid rotation, but the frontal occipital manual technique seems like it is also promoting right sphenoid rotation. I am unclear on what I am trying to achieve with this manual technique. Also, upon the exhalation phase it says to guide the left wing of the sphenoid anteriorly with the right thumb as the index/middle finger drives the right wing of the sphenoid caudally. This seems awkward and difficult to coordinate. (I feel comfortable with the inhalation phase of pulling and supinating). Any clarification on the technique would be greatly appreciated.

The mastoid (temporal bone) is anterior (posteriorly rotated) on the right side and the occiput is in flexion on C1, or in anterior rotation.  So essentially the posterior temporal bone is in extension on the occiput and the occiput is flexed at the OA joint.
The right frontal occipital manual technique promotes right occipital posterior rotation and therefore left sphenoid rotation as the sphenobasilar joint on the right is directed into flexion and the OA joint into extension.
Consider the right thumb as a stabilizer of the sphenoid on exhalation and remember the sphenoid is not your main manual point of interest; the temporal bones are.

How do you approach to post-operative patients from a PRI perspecitve? We have so many ACL reconstruction patients and I would like to know how you use PRI?

You will need to stay close to the physician rehab protocol early in the process (to complement early phases of necessary healing), but as soon as they can bear weight and walk without assistive device or external bracing, they should be able to incorporate functional PRI activities.  Remember, PRI activities are just gait and breathing, so if you can walk and breathe you should be able to incorporate PRI activities into the program.  We have been able to greatly accelerate post ACL reconstruction rehab protocols by finding the appropriate left AFIR and right AFER muscles as early in the process as possible.  And if both left and right “hole control” and hamstring activation is optimized, the risk for post surgical complication goes way down.

-James Anderson, MPT, PRC