Incorporating PRI into Physical Therapy Practice

When I joined the team at TherapydiaSF I came to learn that our facility is trained in an approach known in America as PRI (postural restoration institution) which in a nutshell, provides an assessment and treatment framework for musculoskeletal problems from a vastly different perspective to that of traditional PT. At first I was open to learning new ideas... until I realised that deep down I wasn't. How can I go through so much schooling, a bachelor degree, a master's degrees, and then a 3 year-long requalification to change my perspective and methods on how patient assessment and management should occur? Safe to say, it has been an interesting journey and challenge in taking on knew ideas as I slowly make my way (dragging my heels) into the world of PRI.

Screen Shot 2018-03-27 at 8.11.16 AM.png

I took the first three primary courses (myokinematic restoration, postural respiration and pelvic restoration) at the beginning my time at TherapydiaSF. What I came to understand is that PRI is founded in a cross-section of ideas drawn from both Physical Therapy and Osteopathic fields.

At times the verbiage and ideas are so contrasting to Physical Therapy that it takes me a moment to digest what is being said. Never before has it been so challenging to understand, remember and implement a new framework of thinking. It basically feels like I am trying to fast track my way into thinking like both an Osteopath and PT. 

"We are invited, with respect, to take some approaches from other professions and bring them to the front of our approach." James Anderson, PRI instructor. 

Things I really love about PRI:

  • Breathing cueing. Studying PRI has motivated me to learn more about breathing, the physiology, the assessment and the treatment, which have been covered in recent blogs. 
  • Manual techniques for the ribcage.
  • Emphasis on serratus anterior, internal obliques and triceps.
  • Emphasis on hamstrings and gluteals.
  • An explanation for how a lack of cervical stability can contribute to pelvic pain, or how abnormal breathing drives abnormal muscle activity in the shoulder, back and hips.
  • The techniques for aligning the hips, centring the pelvis, activating abdominals, cueing breathing and describing postural control at the shoulder girdle are easily implemented into my current Pilates routines which allows me to teach these methods in a parallel approach. 

Things I'm not so sure about:

  • Providing a home exercise program that trains the left side of the body differently to the right (which may often be the case initially).
  • Providing a subjective rating of gait observation.
  • Using an assessment algorithm that uses tests not familiar to other Physical Therapists (Hruska adduction lift test, adduction drop test, a squat assessment with a different 5 point grading scale). 

Things that concern me:

  • Developing thought viruses about neutrality, alignment and moving with imbalances. 
    • PRI uses osteopathic terms (in comparison to my Australian training) such as osseous structure, anterior rotation, pelvic inlet and outlet, pelvic diaphragm, to describe the movement of the hips and pelvis during gait. I believe our profession is currently combating thought viruses, especially in the field of chronic pain management. What concerns me is how therapists and patients may interpret terms around symmetry and alignment. 
    • PRI also uses familiar terms such as planes of movement, reciprocal and alternating movement, inhibition and facilitation of muscles, symmetry and synchrony. These are all words we are familiar with, but can overlook the importance of their meaning. 
    • In general, we have a long way to go before our profession is speaking the same language, which is something I think is imperative to our success and growth.
  • Creating dependency if patients don't know how to self-assess and manage their symptoms
  • Looking at patients with a pre-existing bias about what you will find based on the framework presented that "most patient's will present with this..."
  • Not keeping in mind the anatomical diagnosis (if there is one) and the psychosocial contributions to pain - PRI is heavily focussed on biomechanics and the impact it has on anatomy. 

12 months later... 

12 months later and I can now see ways in which this approach significantly benefits me and ways in which it contradicts/challenges my current methods. Granted that my caseload is a mix of musculoskeletal pain conditions, post-surgical patients and Pilates clients - implementing these ideas at the right time is where I might be struggling most. I have been told that there may come a point at which our approach from Physical Therapy hits a ceiling effect with patients and to push forward to help them recover further and beyond re-injury, PRI can tell us a lot more about how they move

I know understand more fully that the aims of PRI are to:

  • Bring back breathing
  • Focus on the diaphragm of the lungs and the pelvic floor working synchronously
  • Viewing muscles as they act in polyarticular chains, not individual units
  • Understand how asymmetry occurs in general and common patterns
  • Provide a foundation for promoting optimal posture within their model. 

What I still need to understand:

Screen Shot 2018-03-27 at 8.14.30 AM.png

As I mentioned above, I have only taken three primary courses and PRI offers three secondary courses and a certification training program. At first is seemed that everyone got the same program which I reacted negatively towards because I disagree with prescriptive approaches. What I came to appreciate from the course is that the program is not the same for everyone but they have created an universal framework that can be applied to a very large range of patient populations. 

It is safe to say I am at the very early stages of understanding their research, ideas and approaches to managing patient care. As I move forward in my training and start to implement their treatment strategies more I think there are two main areas in which I need to understand where it all fits together. Perhaps at a later stage I may come back to these ideas and share what I have found. 

  • How this approach fits with managing acute pain conditions or acute structural injury.
  • How to bridge from a PRI approach into sport specific training and strength and conditioning.

For those that are considering talking these courses, I would like to finish by saying, open your mind and listen with an non judgemental ear. Having been through a gruelling 2 year masters-degree I know confidently that my level of scepticism is on the heavier side which makes it hard for me to hear things in a different way. But listen, and you'll be surprised with what you might learn.