Athletics

Author's Note: The following is an article I wrote for my blog, Integrative Human Performance.  I intend to turn it into a three-part series aimed at introducing patients and professionals alike to the basics of PRI.  Click here to view the post in its original format.

An Introduction to the Postural Restoration Institute, Part 1: The Neurological Nature of PRI

If you’ve worked with, talked to, or read articles by myself in the last few years, then you’ve inevitably heard me discuss or reference the Postural Restoration Institute.  While PRI has become quite popular in many circles within the physical therapy and strength and conditioning fields, there are still many practitioners and non-experts alike who have not heard of it or don’t fully understand what it is.  So, I’m going to do my best to introduce PRI, explain why I find it useful, and discuss how I implement it in my programs.  Due to the abundance of information that this entails, I’ve decided to split this into a three-part series; this first installment will cover the history of PRI as well as the neurological foundation on which it is based.

The History of PRI

The Postural Restoration Institute was founded in 1999 in Lincoln, Nebraska by physical therapist Ron Hruska.  Over the course of his clinical experience to that point, Ron had noticed specific patterns in the majority of his patients and found that, despite the varying nature of their issues, a common approach to their treatment often resulted in significant improvement in function.  As a result, he focused on learning about the asymmetrical nature of the human body and how to integrate those imbalances into a treatment program. Thus, the science behind PRI was born. 

But what exactly is PRI? For many, the buzzword “posture” immediately comes to mind.  This is not entirely inaccurate, since assessment of static and dynamic posture and subsequent attempts to restore neutrality are a critical component of the PRI treatment philosophy.  But rather than the be-all-end-all, posture is more of a means to an end for PRI practitioners–it’s a valuable tool for assessing the neurobiological state of the patient.  To sum up a tremendously complex methodology as succinctly as possible, PRI is a treatment approach that assesses the adaptability of the nervous system to various environmental stimuli via autonomic nervous system-mediated muscle activity and movement.  That’s quite a mouthful, so let’s see if I can break it down for you, starting with the structure and function of the autonomic nervous system.

The Autonomic Nervous System: Structure

If you think back to your high school or college anatomy class, you might recall that there are a bunch of subdivisions of the nervous system.  The first subdivision is made up of the Central Nervous System (CNS), which consists of the brain and spinal cord, and the Peripheral Nervous System (PNS), which consists of all of the nerves and ganglia that lie outside of the brain and spinal cord.  Depending on the source, you might see the Peripheral Nervous System then subdivided into sensory and motor divisions, with the Autonomic Nervous System (ANS) being a further subdivision of the latter.  This isn’t entirely accurate, however, since the ANS does contain sensory afferents.  In fact, the parceling of the ANS into the Peripheral Nervous System is also not exactly correct, since the cell bodies for some neurons of the ANS reside in the gray matter of the spinal cord. In addition, the executive control of many of the functions of the ANS belong to the medulla in the brainstem, while regulatory control belongs to other structures of the limbic system. In order to appreciate the wide-ranging physiological effects that the autonomic nervous system has, it is important to understand that there is significant interplay and overlap between it and what are traditionally considered the Somatic Nervous System–the division of the PNS typically associated with voluntary movements of skeletal muscle–and the Central Nervous System.

The Autonomic Nervous System: Function

 

Direct Influences on Skeletal Muscle

In general, the autonomic nervous system monitors and controls visceral functions that are below the level of consciousness, including breathing, heart rate, salivation, perspiration, and pupillary dilation.  Though there is limited evidence of direct modulation of skeletal muscle activity by the autonomic nervous system in humans, there is a much larger body of evidence in experimental animals, such as cats and rabbits. It has been proposed, for example, that thin, unmyelinated sympathetic efferents innervate intrafusal muscle fibers in muscle spindles, which monitor and regulate muscle length and tone. Again, while the bulk of the evidence is in experimental animals, these findings would imply that an increase in sympathetic outflow could affect skeletal muscle tone or length. Furthermore, beta-adrenergic receptors have been confirmed to be present on the sarcolemma of muscle cells.  These receptors have a particularly high affinity for epinephrine (EPI), which is a hormone released by the adrenal medulla following sympathetic nervous system activation by post-ganglionic sympathetic fibers. This presence could have a number of potential effects on skeletal muscle, each of which have varying levels of in vitro and in vivo evidence in animals and humans, including:

-potentiation of the Na+/K+ pump to attenuate fatigue

-augmentation of acetylcholine (ACh) release at the motor end plate

-a positive inotropic effect (an increase in twitch force) due to interaction with ryanodine receptors that increases calcium ion release from the sarcoplasmic reticulum

-a positive lusotropic effect (an increase in relaxation rate) due to interaction with the calcium ion pump inhibitor phospholamban that increases calcium ion reuptake into the sarcoplasmic reticulum

Interestingly, the beta-adrenergic receptors are more densely distributed on Type I muscle fibers than Type II muscle fibers. Coupled with the fact that Type II fibers lack phospholamban, it is possible that the aforementioned effects are more prominent in Type I muscle fibers, which are generally present in higher proportions in anti-gravity postural muscles such as the hamstrings and in lower proportions in hip flexors like the vastes muscles.  This will come into play in later installments of this series when I discuss specific patterns of motor activity described by the PRI model.  The takeaway here is that the autonomic nervous system–specifically the sympathetic division–may exert some degree of direct influence over skeletal muscle, enabling it to augment motor output factors such as muscle tone, muscle length, twitch force, and relaxation rate.

Indirect Effects on Skeletal Muscle

The ANS can also affect skeletal muscle independent of the aforementioned direct mechanisms. Indirect effects are due to closely-tied neural pathways.  Limbic system inputs to the reticular formation in the pons and medulla modulate autonomic function as well as posture and muscle tone via the descending pathways of the reticulospinal tract.  The limbic system is largely responsible for functions dealing with emotion, behavior, motivation, and threat appraisal, which would make sense in the context of its relation to autonomic and muscle function; emotional responses such as fear or arousal are known to affect both autonomic functions (such as blood pressure and ventilation rate) via autonomic ganglia as well as resting muscle tone via gamma motor neurons that innervate the intrafusal muscle fibers of muscle spindles.  The takeaway, then, is that regardless of the strength of the evidence supporting a direct effect of the ANS on skeletal muscle, the ANS undoubtedly influences characteristics of skeletal muscle and motor activity indirectly via subcortical input and reticulospinal pathways in response to emotional or threatening stimuli.  

Subdivisions of the Autonomic Nervous System

The autonomic nervous system itself can be further subdivided into parasympathetic and sympathetic divisions.  The parasympathetic division is usually characterized as responsible for “rest and digest” functions, while the sympathetic division is characterized as responsible for “fight or flight” functions.  While sympathetic activation can generally be thought of as an increase in effector activity and parasympathetic activation can generally be thought of as a decrease in effector activity, this is not always the case.  It is important to note, however, that most organs receive dual innervation by both divisions, which are concomitantly active to varying degrees.  Thus, while someone might be described as being in a “sympathetic state,” that does not mean that the parasympathetic division has been turned off. Rather, it means that the parasympathetic division’s input has been decreased or its associated receptors have been down-regulated or desensitized.

The sympathetic nervous system is known to be activated by stress.  The human body is effectively indiscriminate about the nature of the stress, which means that psychological, emotional, and physical stresses elicit a similar response, although that response may vary in intensity.  While many are quick to demonize sympathetic activity and frame it as detrimental to health, it would be shortsighted to overlook the fact that sympathetic nervous system activation is a normal physiological response that is necessary for our survival.  Problems can arise, however, when the sympathetic nervous system is overstimulated as a result of chronic stress and/or the Ventral Vagal Complex (VVC), a branch of the vagus nerve which is normally responsible for inhibiting sympathetic response in the face of stress, fails to do so.

Much like the sympathetic system, the parasympathetic system is physiologically crucial to our survival, and decreasing its activity secondary to increased activation of the sympathetic system can impair the “rest and digest” functions that are critical to recovery and general physical and mental health.  Thus, if we constantly bombard ourselves with various forms of stress and/or impair the ability of the VVC to regulate sympathetic output, never letting the ratio of autonomic activity return to a state that’s more parasympathetic-dominant, then we are promoting rigidity of the autonomic system, which impairs our ability to adapt to different stressful stimuli.  To put it another way, the VVC acting as a brake on sympathetic output allows us to respond to stresses in a variety of ways; we can respond to a certain stress with self-calming or with social behaviors, or we can respond with the typical fight or flight response.  Failure of the VVC to inhibit defensive neural circuits, however, limits us to a single type of response that is, when chronically activated, extremely costly both physically and mentally.  Using the analogy of a light switch, it’s not that “turning on” the switch is problematic, it’s that being unable to “turn the switch off” can prove to be costly in the long run.

Wrapping Up: Practical Implications

Why should you care about any of this?  With regards to athletes, it’s been said that the best are not the ones who can get “jacked up,” or into a sympathetic-dominant state, the fastest, but rather the ones who can most efficiently switch out of a sympathetic-dominant state and into a more parasympathetic-dominant resting state.  This makes sense logically: if you’re not working, then you should be resting to conserve and restore energy, and an inability of the nervous system to adapt to this change in stimuli or to depress sympathetic activation in the face of stress (via VVC activity) and shift autonomic states can impair this process.  This notion has been bolstered by studies examining the relationship between vagal tone and heart rate variability, which are known to reflect autonomic nervous system activity and have been linked to general health concerns such as cardiovascular disease, hypertension, and depression, as well as fitness-specific concerns such as overtraining or detraining. With regards to the general population, it is possible that this same mechanism is related to the biopsychosocial model of pain. Psychological and social stress has been linked to failure to alleviate conditions involving pain, so it is possible that failure of the VVC complex to mitigate chronic sympathetic activation plays a role. While this has been postulated in the literature, the evidence for this particular relationship in vivo in humans is scant at this point in time.

With the link between the ANS and motor output (primarily via sympathetic influence on skeletal muscle activity) established, I will delve into the specific patterns of activity that PRI describes and how to identify and address them in the next two posts in this series. My goal for this post was to get you to understand that while on the surface PRI methods may seem to address undesirable postural patterns and suboptimal muscle activity, the actual underlying philosophical nature of treatment is to address imbalance in the activity of the nervous system and restore the ability of the ANS to adapt to various environmental stimuli. In the words of PRI practitioner/preacher Mike Cantrell: “PRI is all neuro, all the time.”

 

References

  • Roatta S & Farina D: Sympathetic actions on the skeletal muscle. Exerc Sport Sci Rev. 2010;38(1): 31-35.
  • Passatore M & Roatta S: Influence of sympathetic nervous system on sensorimotor function: whiplash associated disorders (WAD) as a model. Euro J Appl Physiol. 2006;98: 423-449.
  • Santini M & Ibata Y: The fine structure of thin unmyelinated axons within muscle spindles. Brain Research. 1971;33: 289-302.
  • Ondicova K & Mravec B: Multilevel interactions between the sympathetic and parasympathetic nervous systems: a mini-review. Endocr Regul. 2010;44(2): 69-75.
  • Boulton et. al: Effects of contraction intensity on sympathetic nerve activity to active human skeletal muscle. Front Physiol. 2014;5: 194.
  • Birznieks et. al: Modulation of human muscle spindle discharge by arterial pulsations – functional effects and consequences. PLoS one 7.4, 2012.
  • Lynch G & Ryall J: Role of β-adrenoceptor signaling in skeletal muscle: implications for muscle wasting and disease. Physiological Reviews. 2008;88(2): 729-767.
  • Knutson G & Owens E: Active and passive characteristics of muscle tone and their relationship to models of subluxation/joint dysfunction. J Can Chiropr Assoc. 2003;47(4): 269-283.
  • Alvares G et. al: Reduced heart rate variability in social anxiety disorder: associations with gender and symptom severity. PLoS one 8.7, 2013.
Posted October 23, 2014 at 3:00AM
Categories: Courses Athletics

When James Anderson asked me if I thought there would be interest in a PRI Affiliate Course for Yoga one year ago, neither of us would have believed that it would bring together 60 people for the first course. Participants came from all across North America representing various health, fitness, and coaching professions. Over 1/3 of the participants were yoga instructors (including James' wonderful new wife Karen) with no formal PRI training prior. Welcome to PRI Nation, yogis!

We dove right in Saturday morning with James presenting his Affiliate Course overview of PRI. The audience gained appreciation for PRI's unique -and asymmetrical- platform and our un-waivering respect for neurology, respiration, and biomechanics. By specifically highlighting how the Left AIC and Right BC patterns impair ZOA, gait, and availability of motion, he began the conversation on how yoga can equally optimize or minimize an individual's neutrality. After lunch, I introduced the PRI Yoga Screens, PRI Yoga Awareness Sites (PRIYAS) with a hat tip to Impingement & Instability Reference Centers, and key PRI Opposition Muscles to be mindful of in yoga. I hope that these  screening tools will empower yoga teachers to feel confident in understanding the outcomes of their intervention as well as provide the basis for a referral to -and clear communication with- a PRI clinician. These screens introduced non-clinicians to the A-B-A world of PRI and will undoubtedly demonstrate the value of PRI Yoga to their clients. The PRI Assessment Poses are yogic manifestations of the Hruska Adduction Lift Test and proved to be playful ways of finding the PRIYAS hidden in the poses. 

Throughout Sunday, we explored PRI Yoga poses (asana) in movement labs interspersed throughout the day. I taught asanas that emphasized one or integrated all three planes of movement. I especially loved sharing Bollywood and Warrior 3 as they are equally inspired by yoga's birthplace and by PRI non-manual techniques; they also optimize late left stance and early right stance respectively. We modified the traditional movement sequences of the sun and moon salutations with many students feeling more neutral after just one round. Next, we focused a new PRI "P" word with pranayama or breathing practices that attained and maintained the ZOA.  In closing, I offered recommendations on sequencing a yoga class to parallel a PRI treatment progression and provided PRI Yoga interventions based on potential PRI Yoga Screen outcomes. 

It was a full weekend marrying the complementary aspects of PRI and Yoga. We received gracious feedback and look forward to offering it again next year with some of the first-time glitches fixed. This course brought together two vast bodies of knowledge and left all of us in awe of the similarities and the breadth of these healing paths. I am humbled and honored to share it with you all.

You can also visit Shine Integration Physical Therapy's website and the Postural Restoration Integration for Yoga Facebook page for more photos and course review. Namaste'!

Posted September 17, 2014 at 8:55PM
Categories: Courses Athletics

Kentaro "Kenny" Ishii, ATC, PRT was featured in the spotlight article in Cramer's First Aider Newsletter. If you haven't seen this newsletter in your inbox, Kenny did a great job discussing PRI and his work as the Head Athletic Trainer and Rehabilitation Coordinator with Sporting KC MLS team. CLICK HERE to read the article!

We are excited to announce a new PRI Vision course, PRI Vision Integration for the Baseball Player! This course will be taught by Dr. Heidi Wise and Ron Hruska, and will be offered the day after the PRI Integration for Baseball courses scheduled this November.

"This will be a different course from our Postural-Visual Integration course.  We we will be introducing assessments specific to baseball that help those working with the players in the training room understand when the visual process is affecting players’ physical ability to bat and throw.  There will also be concepts and activities taught that can be used in the training room and on the field to help reduce negative visual influences on the visual influences on these abilities, even without additional integration with an optometrist. “ – Dr. Heidi Wise, OD, FCOVD

To learn more about this course and to register click here.

Posted July 30, 2014 at 7:06PM

John Nyland did a nice job commenting on sports specialization in his editorial article in the June issue of JOSPT. If you have access to this article, be sure to take a look at it. Experiencing diversification in "physical, cognitive, affective and psychosocial environments" at all ages, probably also contributes to transfer of learning between cognitive, psychobehavioral and physical neurological processes.

Posted June 23, 2014 at 9:42PM
Categories: Athletics Articles

Hi everyone! I just wanted to share a fantastic experience I had earlier this month!

I was invited to speak at SPATS (South Padre Athletic Training Seminar) hosted by VATA (Valley Athletic Trainers’ Association) last weekend. Since they gave me a total liberty of picking my own presentation topic, I took full advantage of it and decided to use that opportunity to spread the PRI word. My lecture topic was “Let’s Blow Up a Balloon! Breathing in Orthopedic Rehabilitation.”  Since my time was limited, I choose not to go in depth on the polyarticular chains and explain all the PRI terminology (i.e. L AIC, R BC etc). Instead, I focused on the left-and-right difference of the diaphragm, the importance of restoring the ZOA, and learning how to…EXHALE!!!! There were many attendees (mostly ATs, but also some PTs, DCs and MDs) and it was truly fun to watch approximately 300 people blowing up balloons! It was very well-received as many participants came to talk to me afterwards, asking about the PRI concepts and courses. I am glad to say there’s a growing interest in PRI down here in South Texas!

CLICK HERE to view my presentation!

CLICK HERE to read faculty member, Mike Cantrell's newest paper that he has written titled "The Soccer Player's Tug of War: A Simple Understanding of Athletic Pubalgia and Sports Hernias".

Posted June 13, 2014 at 4:18PM
Categories: Clinicians Athletics

Check out this newly released article by Emily Soiney, titled "Taking Yoga to the Next Level-Postural Restoration-Inspired Yoga for the Athlete: The Frontal Plane". Emily is also busy preparing for the first PRI Integration for Yoga affiliate course which will be held in Portland, OR on September 13-14th! Additional seats have just been opened for this course, so if you are interested in attending be sure to reserve your seat today. CLICK HERE to register!

This past week, PRI has been featured in two different news outlet stories!

Yesterday's issue of the USA Today included an article about Arizona Diamondbacks pitcher Bronson Arroyo and his stategy to stay off the disabled list, which includes PRI and blowing up balloons. CLICK HERE to read the article online. PRT's Neil Rampe and Andrew Hauser along with the entire Arizona Diamondbacks athletic medicine and performance staff deserves some kudos here!
 

In another story, PRC therapist Jon Schultz from Des Moines, IA was featured by a local television station KCCI News8 in the story titled "How Learning to Breathe Could Help Your Recovery". To see this great video, CLICK HERE!

Posted March 28, 2014 at 6:31PM

Michael Mullin, ATC, PTA, PRC was featured in this month's issue of Training and Conditioning. If you received your issue in the mail, be sure to check out Michael's article titled "Finding Balance" on pages 28-33, or CLICK HERE to access the online version. The hard copy however features photos which do not accompany the online version, and is a great resource for clinicians and patients as well. Great job Michael!

If interested, you can sign up for a free subscription to this publication, Training and Conditioning.

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