I recently had the opportunity to take PRI’s Impingement & Instability (I&I)course for the first time. The most important concept from this course, in my opinion, is that if patients can’t recognize, use, and integrate the sensory references need for upright, alternating, reciprocal function—the goal of any PRI program—then they will not be successful in their program. And neither will you. Definitely not something that excites most of us, regardless of whether you are a PT, strength and conditioning coach, trainer, or even an optometrist, dentist, podiatrist….the list could go on and include anyone working with this patient, whether to improve performance, decrease/prevent pain, or treat their orthostatic or anxiety issues. Impingement & Instability is the “bridge” course between the primary, “floor-up” PRI courses and the “top-down” secondary courses and the PRI Vision course.
I&I concepts are the type of thinking that, in some regards, are the only thing I really know how to do when it comes to PRI. I am not a PT, nor do I have any formal educational background in human gait, movement, or physical performance. The minute a term like “anterior pelvic inlet” or “late left stance” comes out of Ron’s mouth, I’m a little lost. I’ve learned a lot over the past 5 years working with Ron and the other therapists here at the clinic, but this is why I keep taking and retaking courses! Anyone who knows me knows how much I HATE that feeling! But what I do clinically every day in PRI Vision with Ron is ALL about sensory awareness. So for the patients that need me, I know if they can’t consciously “find & feel” the floor under their left foot—in I&I the left calcaneus—nothing I have done so far will help them and we have to keep going until they can.
There are, of course, other sensory references many patients need to increase or decrease. Some of them are discussed in I&I, some are not, and these vary based on the patient. Regardless of what these are, my job is to change the “top-down” brain’s sensory awareness so that the “bottom-up” activity from the primary courses can be effective.
The second concept for this course is the meaning of the words impingent and instability. Impingement as a syndrome or diagnosis is usually associated with pain due to excessive or inappropriate contact between two points in the body. Instability is usually associated with the lack of support or stability, often due to overstretched or lax ligaments or muscles. But consider these definitions:
Impingement: appropriate contact not only between two points in the body, but also between the body and a needed sensory reference, such as the floor.
Instability: the freedom to “let go” of a contact point, sensory or physical, so movement can take place. To obtain alternating, reciprocal function, you need proper impingement on one side paired with proper instability on the other, then the ability to reverse it—This is how “good gait” happens!
Every patient I see in PRI Vision needs less impingement and less instability in certain areas, and more of each in other areas. Many have too much “impingement,” or reliance, on vision, and not enough on their left heel. We also frequently have to change multiple reference areas for the patient to make use of the new “instability” I am giving them in Vision. These changes can be the determining factor in the patient’s program success, and where I rely fully on Ron and the referring therapist to ensure this is accomplished when needed.
If you haven’t taken I&I, you absolutely should! Ask some of the attendees that experienced the “right” PRI function for the first time during those two days. If you’ve taken I&I, then the next step is to take the Cervical Rotation and Postural-Visual Integration courses. These two courses will show you what to do when you have patients (or yourself!) that just can’t find and keep those sensory references from the I&I course. The head, neck, and ultimately the BRAIN are the “top-down” drivers that can negate, or reinforce, all of your and your patients’ “floor-up” hard work.
Moving Beyond Sight!