I have a question on the most recent clip regarding cervical axial rotation and decending vs. acsending issues.  Listening to Jen’s patient case study sounded very familiar as I have a patient struggling with right sided neck pain and headaches who is slowly getting better but not over the hump. Neutral BC except we have trouble keeping keep axial rotation to the left.  So I tried the modified exercises with her today.  With each one I could not get her to feel her left SCM and in fact all she felt was her right neck working to the point of creating some discomfort that she hadn’t had in awhile.  Is there a better cue to use to engage her left SCM or was she just not stable enough proximally (have just started upright right serratus work with her) to be able to keep her right neck off?

Ask your patient to sit upright first and find and feel or search for her left SCM by moving her chin down toward her right chest and slightly sidebend to the left.  Compare this activity to the other side…or consider starting with the other side first to help with associated movement that is denied on the left.  Then try the sidelying left SCM recommendations.  If this fails consider supine activation (see Florence Kendall recommendations).  You’re also correct in your thinking; regarding right SA, lower trap, and tricep instability.  This may be the chief issue.

Describe the intent of the bolster for the Left Sidelying Right Glute Max, Left Sidelying Knee Toward Knee and Right Sidelying Adductor Pull Back exercises.  Is the bolster under the feet for sidelying exercises there to increase the ROM that the hips have to go through…..Left Sidelying Right Glute Max to increase right hip ER ROM?  Left Sidelying Knee to Knee to increase right hip ER and left hip IR (help activate left anterior glute med and IC adductor magnus more via shortening it w/ hip IR positioning)?  What about bolster in between both legs for Adductor Pull Back….that puts left hip into more IR.

The bolster under the ankles, when the patient is in left sidelying, is to help align the medial malleolus with the pube. It also gives the patient the sensation or proprioceptive input to “turn” the right knee up (right FA ER) and “turn” the left knee up for left FA IR. It places the left ischiocondylar adductor and the right FA ER’s in better transverse plane position. The bolster between the ankles when in right sideyling helps increase left FA IR with left adductors (left ischicondylar adductors).

How would you describe adductor activation as facilitating pelvic floor activation?  E.g. if you do a Left Sidelying Knee to Knee exercise…..are you activating the right pelvic floor muscles via a polyarticular chain between the left ischiocondylar adductor magnus and the right pelvic floor?

Adductor activation requires pelvic floor co-contraction by the levator ani group, the obturators, and the coccygeus muscle.

A Left Sidelying Knee to Knee requires right FA ER and left FA IR…so right pelvic floor is probably co-contracting more than the left with right FA ER and left pelvic floor more with left FA IR/ischiocondylar adductor. None the less the pelvic floor has to be working for successful adduction and abduction without arcuate ligament or pube pain.

Describe your rationale for inhalation with the Adductor Pull Back (pulling back portion) and exhalation with the IR/ADD (towel squeeze portion)?  Exhalation into IR is the normal movement for exhalation and would help optimize ZOA….but what about the inhalation phase?

When one ‘pulls’ back the left leg upon inhalation, the left ZOA is enhanced (left anterior iliac spine goes posteriorly and left lower ribs approximate the left ASIS resulting in better positional left ZOA) and the diaphragm upon contraction forces the left pelvic floor fulcrum (levator ani muscle group and coccygeus) to open and stretch so that upright left AF IR will be more easily obtained and not limited by the left pelvic floor. You want to feel left adductor, not the left hamstring as your left posterior hip capsule feels stretched.

During a conversation with a colleague a confusing issue came up.  PRI stuff is interesting and one of the things that is most interesting to me is that they pretty much say “everyone has this presentation” (left anterior, tension in right hamstring, anterior tilt, etc…). If you have ever read Wolf Schamberger’s “Malalignment Syndrome”, he actually talks about the most common presentation being people anteriorly rotated on the right, posterior on the left – which is opposite to PRI’s thought process.  Who is right?  I think it is okay to notice trends (I have actually seen more people fall in the presentation from the Malalignment Syndrome – anterior rotation on right), but to group everyone into the same presentation is a bit strange.

It’s all a matter of perspective, which is what PRI challenges the most.  Humans lateralize their center of gravity to the right more than to the left because of many objective reasons.  If one establishes a neuromuscular pattern of stable, secure foundation through the right lower extremity, utilizing the right vastus lateralis, right hamstring, right adductors and right gluteus medius, you will find an anteriorly positioned or oriented innominate on the right.  Subsequently, the left ASIS may “feel” more anteriorly rotated on the left and possibly the evaluator may “find” the right innominate more posteriorly rotated on the right.  Inter-rater reliability in these situations, without further integrated objective testing is poor at best.  In this case, in standing, the evaluator would find more lumbar-thoracic lordosis on the left. 

If one becomes lordotic bilaterally, as often is seen with those who are tight and over-active with their posterior exterior chained paravertebrals (PEC patients) the right and left innominates move in an anteriorly rotated direction around the frontal axis going through both central acetabulums.  Discussing axis of the sacral rotation complex, varies in every individual and has no validation in today’s research.  This individual will now need to begin moving the left innominate out or externally rotated it around the vertical left SI axis to offset weight distribution to the right, resulting in:

Hyperactive right quadratus lumborum activity
Hyperactive left gluteus maximus and TFL
Hypermobility and possible laxity of left pubefemoral and iliofemoral ligament and soft tissue
Inhibition of left adductor and hamstrings
A left ASIS that feels “posteriorly” rotated compared to the “anteriorly” rotated right innominate

I am fairly certain, this compensatory activity associated with the human characteristic pattern of bilateral innominate anterior rotation (lumbar-thoracic lordosis) is what the “Wolf Schamberger’s Malalignment Syndrome” is all about. 
Again, it’s all about perspective, position and pattern of the tester and the tested.  Please realize that palpating ASIS’s and PSIS’s of those in sitting, standing, on one leg, supine, etc all result in various, ambiguous outcomes…a whole different discussion and set of circumstances. 

How will the left iliacus act as an internal rotator on the left?  I have it working bi-planar for IR on the frontal plane and flexion on the sagittal plane.  I am thinking this occurs based on the forward (anterior) and ER positioning of the ilium on the femur in standing but I still have difficulty seeing the IR there.

The left iliacus acts as an AF IR stabilizer on the left.  It’s acting as an AF motion, not FA.  The left iliacus doesn’t perform AF IR, it stabilizes you there once you are shifted into AF IR.

In the Myokinematic Restoration course manual what does “Antigravitational ER’s and “Positioned ER’s” mean? 

The Top 3 anti-gravitational external rotators are the muscles that are powerful against gravity.  You want to turn these muscles on when in an anti gravitational position because of their power.  These 3 muscles may or may not be in a correct position but they are powerful when fighting against resistance.

The Top 3 powerful positioned external rotators are the muscles that are the most powerful after they have been “repositioned”.  After you have repositioned the patient’s pelvis, if you want to go after strength and power, you would go after these 3 muscles.

This would be the same for the IR muscles listed.

Most strength coaches attempt to lift with the back locked in neutral (neutral lordosis).  The rule of thumb is to preserve the curve in the low back with lifting.  They are afraid to have their athletes lift with flexed backs. They point out the research done by Stuart McGill to justify their lifting techniques. This research shows that lumbar flexion adds compression and shearing forces on the spine especially at L4 and L5. He also recommends not doing a posterior pelvic tilt because it loads the passive tissues of the spine. I know this goes against PRI guidelines. I am just wondering what you think of Mcgill’s research?

Thank you for the information on Stuart McGill.  PRI activity incorporates proper breathing with co-activation of the abs and back extensors, lifting with proper assistance from glutes and hamstrings and reaching without over extending the thorax.  We also want to keep the lumbar spine as neutral as possible.  The problem lies with those losing lumbar lordosis early on or in the middle of their lifting sequence and therefore relying on L5-S1 ligament, sacral iliac posterior ligament, and pelvic floor ligament attached to the lower sacrum for stability and support during a process where lumbar compression is now significantly higher than when you flex the thoracic lumbar spine.  I don’t believe many understand the importance of the lift is to keep the lumbar spine NEUTRAL as the thoracic spine extends when moving upright. PRI does not promote posterior rotation of the innominates during the lift. We promote co-activation of the hamstrings and the hip flexors/diaphragm to offset the torque on the spine. Those who overextend the lumbar spine early in the lift and during thoracic extension at mid ranges of the lift are over-compressing and sheering their thoracic and lumbar intervertebral joints. 

I was hoping to get a little help and information regarding a MTJ patient that I am seeing.  This 50 year old male patient was referred by a DMD whom is knowledgeable of PRI techniques and principles.  Progressive splint/Mago therapy was initiated 8 months ago.  There is internal disc derangement on the right, I am not sure about the left.  Patient is a tongue biter, and demonstrates patterns typical of a R TMCC.  As expected, I have not been able to maintain a ZOA, Left FA IR, Right HG IR and standing posture.  Would you please explain why when I placed 2 tongue depressors on the right molars (while wearing his splint) his shoulders were level, his FA IR improved by 10-15 degrees, negative right HG IR,  and ZOA and chest expansion were restored?  Also he had improved sphenoid flexion and decreased compensatory extension?  Should he continue to perform his PRI exercises (Left AIC and brachial repositioning)?  With tongue depressors?  Should I include any tongue exercises?  He has a “flat” looking tongue and is not comfortable sticking it out, he feels like he could dislocate his jaw (which he reports happens frequently).  Do you think his splinting is appropriate?  Would love any other suggestions.

The tongue depressors temporarily repositions his mandible to his maxilla and allows him to move out of his right TMCC state or pattern and relax his cervical and thoracic stabilizers, possibly through the autonomic nervous system.  What’s important here is the need to keep an appropriate splint in his mouth, at least at night, to assist in this autogenic inhibitory process or the establishment of this skeletal muscle and orthopedic realignment state.

The type of oral appliance used is up to you and his dentist, but an acrylic mandibular Gelb-type of splint would be recommended because of the likelihood that he is off his TMJ disc on the right.  This splint will help bring the mandible slightly forward without having compressive directive forces placed on the TMJ discs.  It will also hopefully relieve some of the stress at the back of the neck and occiput, since the occipital condyle compression forces on the atlanto superior articular facet should be reduced, allowing cervical rotation to resume to the left. You are correct, in my opinion, that cranial flexion will be better permitted, as well as his ZOA, etc.

I would encourage initiating Supine Sacro-Spenoid Flexion, Left Sidelying Knee Toward Knee with Left Trunk Rotation, Seated Adductor Alternating Reciprocal Quad Sets with Right Cervical Sidebending, and bilateral lateral pterygoid activity with slight protrusion; with his new splint in.  The splint he uses needs to keep in the same position that the tongue depressors did.  I wouldn’t rely on the tongue depressors for correct positioning during PRI activity.  I would ask his dentist to work with you in fabricating an appliance that guides, not directs, his mandible slightly forward and decompresses his TMJs

Is there any contraindication to performing manual BC techniques on a patient with SOB due to Sarcoidosis?

There shouldn’t be any contraindications; on the contrary PRI manual techniques should slow the progression of tissue damage and fibrosis of the lung.  Since gradual pulmonary fibrosis, pulmonary insufficiency and pulmonary hypertension are leading causes of disability and death, I would think about appropriate diaphragmatic effort with proper lung/thoracic position and activity would be very appropriate and helpful.

I have a question on the Standing Serratus Squat exercise.  I have seen Ron use that exercise at courses a few times to help with upper trap inhibition.  I have tried to utilize it and have had a tough time getting patients to “feel” serratus working and I/they are not noticing much change in scapular position/upper trap tone etc.  All they feel is quads (which I know is also desirable).  I have emphasized maintaining lumbar flexion (post tilt), steady pressure with forearms and heels down.  Am I missing something or what can I cue my patients to feel serratus better as I have seen this be a very effective exercise but have become frustrated with it.

You are doing everything correctly with the Standing Serratus Squat.  Most often, when you ask the patient to push their forearms into the wall, they will also move their thorax towards the wall.  The key to finding the serratus is to have them push their elbows into the wall and then ask them to pull their rib cage back (thoracic flexion). 

I have found a lot of cheaters with left adduction activities.  When performing activities like the Right Sidelying Left Adductor Pull Back, often times I’ll ask if they feel the left inner thigh.  More recently I have been making patients point to where they feel it and many of them point very high in the left hip (towards the groin).  I’m wondering about substituting lesser adductors for the adductor magnus.  I realize they are synergistic groups, but the IC adductor has a much longer lever arm and has better ability to approximate the hip.  Since they do work together, do I need to be more specific about trying to get more distal adductor activation?

The intent of the Right Sidelying Adductor Pull Back is to “effectively” approximate the femoral head into the acetabulum as the acetabulum moves posteriorly and the femur into IR.  The adductor group, not just the IC adductor, is used to facilitate acetabular motion and femoral approximation.  The IC adductor as a muscle of the adductor complex is most facilitory in this process because of the AF IR and FA IR kinetic activity.  Separating these muscle fibers will not be possible nor is it necessary, in my opinion, for AF IR actualization and “proprioceptive feel” to occur.  This technique is primarily used as a “starting” technique for good AF IR position during FA IR movement.  I would advance the patient ASAP once adductors are felt and desired motion is carried without back extension and improper breathing.