Course Notes: PRI Interdisciplinary Integration 2015

A Stellar Symposium

Back in April I had the pleasure of finally attending PRI’s annual symposium, and what an excellent learning experience.

The theme this year was working with high-powered, extension-driven individuals.

The amount of interdisciplinary overlap in each presentation made for a seamless symposium. Common themes included the brain, stress response, HRV, resilience, and drive. These are things altered in individuals who are highly successful, but may come at a cost to body systems.

If you work with business owners, CEOs, high-level athletes and coaches, high level positions, straight-A students, special forces, and supermoms, this symposium was for you.

Or a combination thereof
Or a combination thereof

And let’s face it; we are both in this category!

There were so many pearls in each presentation that I wish I could write, but let’s view the course a-ha’s.

The Wise Words of Ron

Ron Hruska gave four excellent talks at this symposium regarding high performers and occlusion. Let’s dive into the master’s mind.

Enter at your own risk. Shizzzaahhhh
Enter at your own risk. Shizzzaahhhh

People, PRI does not think extension is bad. Extension is a gift that drives us to excel. Individuals who have high self-efficacy must often “over-extend” themselves. This drive often requires system extension.

Extension is a consequence, and probably a necessary adaptation, of success.

If this drive must be reduced to increase function and/or alter symptoms in these individuals, we have to turn down the volume knob.

How can we power down these individuals?

  1. Limit alternate choices – These folks take a wide view of a task
  2. Set boundaries – These folks attribute failure to external factors
  3. Making initial tasks successful – So these folks don’t give up at early failures
  4. Objectively measure improvement – This helps motivate people to continue
  5. Establish rhythmic activity that reflects specific set goals – the higher the goals the more likely the positive change.
PRI, we have a bobsled team
PRI, we have a bobsled team

A Tale of Two Forward Heads

We discussed a lot of attaining neutrality at the OA joint. What does that entail?

A: Both occipital condyles centered in the atlas fossa with unrestricted lateral flexion.

What is needed to have that?

  1. 55-60 degrees of cervical extension.
  2. Equal bilateral first rib rotation position.
  3. Centric occlusion with the anterior teeth guiding protrusive movement and canines guiding lateral movement.
  4. Normal maxillary and mandibular teeth contact.
  5. Ability to nasal breathe.
  6. Alternating pelvic capability.
  7. Visual flexibility.
  8. Normal hearing bilaterally.

Lose any one of these and a forward head posture may occur.

The two types of FHP we see include one with the atlas migrating forward with increased cervical flexion and occipital protraction.

Forward-Head-Posture

 

And one in which the atlas migrates backward on the occiput in which excessive upper cervical flexion coupled with lower cervical/upper thoracic hyperextension.

images

With the former’s case, these individuals have a harder time feeling posterior teeth; a loss of frontal plane. When one loses frontal plane, the individual must attempt to increase anterior guidance via extension. Strategies used to do this include tongue thrusting, bruxism, fingernail biting, mouth breathing, clenching, etc. These strategies are protective in nature as they limit potential stress at the TMJ and OA.

Most of the latter include your bilaterally extended individuals. They retrude the atlas to significantly increase cervical stability. This hyperstability allows for dominant performance in the sagittal plane. These individuals may need more visual interventions.

 

She’s a Wise Woman

Dr. Heidi Wise gave one of my favorite presentations of the symposium. She discussed vision’s role in extension-driven individuals.

Vision is the most dominant sensory modality, as it has the ability to override all other senses to redirect attention. To me, this is why vision is such a powerful way to get someone neutral.

Redirection of attention through the visual system occurs through saccades. These eye movements occur 85% of the time our eyes are being used. This is how the visual system detects a salient stimulus.

If visual processes hold someone in an extension pattern, it may become extremely difficult to near-impossible to overcome.

Here is how we start thinking a visual process may be promoting an extension pattern:

  • Those who cannot inhibit extension with traditional floor-up activity.
  • Late-onset (past puberty) or severe near-sightedness.
  • People with extremely good eyesight.
  • Folks who over-focus on objects straight ahead (people who stare).
  • People who walk with purpose (makes me think of my mom in the mall!).
  • High-energy.
Probably more than just a vision patient.
Probably more than just a vision patient.

If someone over focuses (read: nearsighted), eye exploration is minimized. It becomes much harder to notice change, or salience. This is how the visual system can keep someone stuck in a stress response.

What is needed to see close?

  • Increases in acetylcholine and norepinephrine.
  • Reflexive increase in neck/head muscle tension. More so if one must strain to see.

Do this too long, and we can see unfavorable autonomic, visual, and neuromuscular stress.

And guess what visual field research is showing we better attune to? The right side; more specifically, the right upper visual field.

The PRI goal? We want to restore ambient vision in these individuals to process three planes of visual motion.

Here were some of Heidi’s recommendations for how to do so.

  1. Take breaks from a task to move.
  2. Be aware of surroundings on both sides without looking when walking.
  3. Walk slower than usual.
  4. Look around using your eyes independent of your head.
  5. If nearsighted, take glasses off occasionally and “be OK” with things far away being blurry. Don’t strain to see well.
  6. Have top of computer screens at about eye level. Look far from the screen as often as possible.
  7. Close eyes and visualize a large open area that makes you calm.
  8. Minimize time on small, close screens and keep object far from eyes.
  9. Read books over e-readers and keep the book as far away as visually comfortable.
  10. Emphasize peripheral awareness before and after high attention tasks.
  11. Change variable such as sounds or environment during high attention tasks.
  12. Get away from looking in the mirror at movements.
  13. Change lightbulbs to natural daylight.
heidi
And Heidi’s as well

 

Mental Muscle

Dr. Todd Stull provided a lot of neat neuroscience nuggests.

  • Glia purges our brain of waste during sleep.
  • Strongest memories are tied to emotions; more negative than positive.
  • If the limbic system is too active (such as in a threatening environment), prefrontal cortex activity goes way down. You can’t learn as well.
  • Cranial nerves are extremely important in social interaction. Nonverbal cues from these areas can unconsciously affect autonomics.
  • During adolescence (12-25) the right side of the brain and limbic system develop faster than the left and neocortex. This lateralization is why this time period can be so emotion-driven.
  • Face to face interaction is needed to cultivate the nervous system. This is the problem with social media and texting.
  • Dopamine pathways are very active during adolescence; it’s one of the reasons addictions start during this time.
  • Feelings of being overwhelmed are 6 times more common in those who have had concussions.
  • Rehearse making mistakes and how you will come out of them.

He also provided some great patient interaction nuggets that I hope to liberally steal.

  • Keep your eyes on the individual and tell them “it’s great to see you here.”
  • If you are not doing well on a given day – “I don’t feel good today but we’re going to have a good session.”
  • If you are at odds with a patient – “We’ve seemed to come to a roadblock. Would you agree?”
Ya don't say?
Ya don’t say?

 

Optimizing Mindsets 

My big takeaway from psychologist Dr. Tracy Heller’s talk was mindfulness.

Mindfulness is something I am hoping to get more into in the future. She defines it as being aware of your thoughts, emotions, physical sensations, and actions in the present moment without judging or criticizing yourself or your experience.

It’s a big deal to have this capability. Practicing mindfulness has been shown to reduced cortisol, stress, pain, depression, and anxiety; while also improving memory, sleep, and cognitive function.

The way we build mindfulness is basically letting go. I like the analogy that I heard while using Headspace (a great app if you haven’t used it). Imagine your thoughts and feelings as cars in traffic. Your goal is to just watch the cars pass by, not chase them. You want to be present in the moment, as we want in most of life.

And if you can do this in LA you'll put most Tibetan monks to shame.
And if you can do this in LA you’ll put most Tibetan monks to shame.

One option of practicing this is resonant frequency breathing, in which we perform 4.5-7 breath cycles per minute. Let the body breathe on it’s own and let the air come in; using terms such as “let,” “allow,” and “permit.” These are cues I have been using much more with patients and has made a big difference.

 

Dad’s Part

This was easily my favorite part of the symposium (I may be biased since my Dad gave this talk). Bill Hartman blew it out of the park teaching us how PRI applies at the highest level of performance.

The rules change in the performance realm because the patterns are incredibly powerful, effective, and efficient. In some cases we may want them. A perfect example that Bill gave: Usain Bolt

Rarely does he cross midline when he runs, making him the fastest runner on one leg. Do we want to change that? Probably not.

Performance does not equal health. Gymnasts for example, may need to create pathology to perform at a high level. Some people must utilize passive elements to produce greater outcomes. Usain Bolt runs on one leg. Everyone is a case-by-case basis. N=1 forever.

What must occur in the performance and health realm is stress management. Acute stressors with recovery make us antifragile; prolonged stressors reduce variability as an allostatic adaptation.

If one must constantly perform at a very high level, where will they be on this stress dichotomy? Prolonged stressors = reduced variability, sympathetic dominance, and system extension.

Variability helps us anticipate demand. It helps us become better able to cope with specific environments and recover movement function. The only way we can know if movement variability is present is through assessing the musculoskeletal system

 “The state of the musculoskeletal system is the other end of the brain” ~ Bill Hartman

If stressed or threatened, body systems use default reflexive mechanisms to combat threat. The brainstem is much faster than the cortex. As a consequence, variability can be lost.

Attaining increased prefrontal cortex activity allows us to inhibit our default response and increase variability. That’s why mindfulness increases HRV, and that’s why a 90/90 hip lift can alter body position.

And why juggling gets Bill neutral. Chainsaws preferred.
And why juggling gets Bill neutral. Chainsaws preferred.

To better manage stress, we must train. Training is a progressive desensitization of threatening input to allow an athlete to perform at adaptive potential with optimal variability and without fatigue.

The higher performance level required, the more difficult it becomes to get neutral. This is what happens during functional overreaching. You gain higher performance output during this timeframe because the sympathetic nervous system and HPA axis are on overdrive.

Applying Bill’s principles along the training and rehab continuum, rehab requires neutrality and variability to rebuild a failed stress tolerance. The amount needed in performance realm will depend on how (in)variant one’s sport is.

The Wild World of Combat

Dallas Wood and Zach Nott work with in a military population, and it was fascinating showing how they mitigate the extension necessary for their clientele to perform. They guys collect a lot of data, and the fun factoid was that about 80-90% of their individuals are PEC and bilateral BC (surprise surprise).

They showed us a very cool auditory case. They had a dude with a PEC/BBC presentation with a history of ear trauma and tinnitus. When they blocked his left ear the gentleman was completely neutral.

A viable treatment in probably more cases than you'd think.
A viable treatment in probably more cases than you’d think.

Treatment underwent reducing the tinnitus by implementing a hearing aid that uses various white/pink noises to slowly reduce tinnitus. Not sure exactly how it works, but this was exciting to hear about (ha). I look forward to learning where PRI takes auditory integration.

 

C’est Fini

 So there you have it. I already signed up for next year’s symposium because this one was so much fun. I look forward to more of the consistently fantastic content that PRI provides. Learn on!

 

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