Treatment at the Hruska Clinic: PRI Dentistry and Vision

PRI Vision:

A first hand snippet into PRI Vision experience. Thanks Zac!

Originally posted on Zac Cupples:

For part 1, click here

Jaws will Drop

 I’m in the dentist chair, The room slowly get darker and darker. I feel my mouth open, and I wasn’t sure what would happen next.

Then Dr. Schnell places the necessary goup in my mouth to get an impression for my splint. I bite, and out comes the finish product.

You live to see another day. Bastards!

You live to see another day. Bastards!

Before the impression was taken, Ron came in and explained what he was hoping to accomplish. He wanted to fit me for a gelb splint to give my tongue some space to move in my crowded mouth. This splint would also help bring my mandible forward.

Dr. Schnell: “Is he neutral right now?”

Ron: [throws a towel over my eyes and sets my neck in a lordosis] “Now he is.”

And with that, the above sequence occurred and I was ready for vision.

Don't forget to bring a towel when you do your PRI exercises. Don’t…

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Through the Looking Glass

Every time Ron and I teach a PRI Vision course, I gain a slightly different appreciation of what I get to be a part of in my life.  That’s because of the people involved.  Each person comes in with their own perception of what vision is and does, because of their own unique looking glass through which they see the world.  These collectively lead the two days in subtly different directions, where some concepts, ideas and activities get more time than others.

This past weekend, we taught our Postural-Visual Integration course in Grayslake, Illinois.  In that room were physical therapists and assistants, athletic trainers, strength and conditioning coaches, corrective exercise specialists, personal trainers, lifelong learners, and even an optometrist.  The variety of titles and occupations, ages, years in their occupation, and each individual’s experience with their own vision are what make teaching, for me, so exciting.  What is so powerful is the interaction of the people around me, each individual focusing their looking glass based on where it started, what they take from what is presented and what others share.

Larry MacDonald, OD, said (paraphrasing) “Eyes don’t tell people what to see.  People (the brain) tell eyes what to look for.”  I wonder how many that were in that room have used their looking glass, with a different focus, this week to see why the people they treat and interact with behave the way they do.  I wonder how many of them have thought “I bet this person might do that activity different if I have them face into a big room instead of look at a wall.”  I hope we inspired them all to have done that at least once.

Isn’t this what we all do every day in life with each experience?  Each experience is perceived differently by the people involved because of their looking glass.  It’s been said that people never really change.  Is that true?  I know I came out of the weekend changed.  I am officially another year older after celebrating a birthday, I gained new friends and further appreciation for ones I already had.  I laughed so hard I couldn’t stand up, met an integrative-thinking woman from Brazil, and found comfort in letting my fear show.  I heard insight and wisdom from those with different backgrounds that at times made me pause in awe.  We talked of dogs, Lady Gaga, the earth’s magnetic pull, feeling the floor, seeing space, baseball, child development, and the beat of the music next door.  Even some of the material we presented struck new chords in me as I got the opportunity to discuss it with those around me, deepening my understanding of and respect for the amazing thing called the human brain.

Yes, it was a course about vision.  But it gave me access to priceless moments for my own looking glass to focus on, making me a better clinician and life participant.  I am changed.  For that, I am grateful for all those who took time to join me this past weekend.

 

As Always, Keep Moving Beyond Sight!

Dr. Heidi

 

Seeing the Floor

In PRI Vision, we spend our clinical days helping patients gain the ability to center themselves in space.  We define centering as the neurological ability to use appropriate visual perception, capitalize on ascending support, and balance on each side.  To center correctly, you must be able to be “neutral” as defined by PRI while performing this task.  However, a person can be “neutral” and still not be able to center.  Even though we are using visual input through the eyes to help patients accomplish this, centering must start with the floor.

Poor Right Centering with Extension

Poor Right Centering with Extension; note how the trunk is fairly straight, rather than flexed, evidenced by lack of side-bending at the waist and from the side view by a flat back.  The whole trunk is leaning to the right with the left leg as counter-balance for the trunk.

Appropriate Right Centering with Flexion

Appropriate Right Centering with Flexion; note how there is a side-bend in the trunk, showing right abdominal engagement for trunk support, rather than the left leg utilized for this purpose.  Her nose lines up well to the right of her midline without head tilting to accomplish this.  From the side view, rounding of the back would be observed, further indicating flexion of the trunk.

Sensory awareness of the floor may seem like an overly simple thing to possess.  We have the patient attempt to center themselves, and then ask them what they feel holding them up.  Especially when on only one leg, many of our PRI VIsion patients can’t answer that question; some of our patients can answer it when on one side, the right for instance, but not when on the left.  The reality is that they really don’t know what muscles they are using.  Some might answer their ankle, knee, back, or even their neck.  Others are concentrating very hard and staring at the ground to help them balance, effectively using muscles around the eyes to help them stabilize themselves; this is another inappropriate substitute for poor sensory floor awareness.  All of these floor-challenged patients have ceased to use the floor for ascending support; instead of pushing down on the floor to fight gravity, they are using extension muscles to pull themselves away from the floor and gravity.  The heel, arch, inner thigh, outer hip, and abdominal muscles, important reference centers in the world of PRI, are not engaged, nor can they find them to activate them even when thinking about it.

The more disconnected a person is from the floor for proprioception and sensory input, the greater the chance that they have overactive neck muscles and associated symptoms.  On the lesser end of the spectrum, they may have neck and/or back tension.  At the more involved end of the spectrum they can also experience dizziness or disorientation, tachycardia, lightheadedness or fainting, and shortness of breath.  In these more involved patients, tension in muscles associated with extension activity is so chronic that it takes the place of appropriate reference centers.  Shutting down those muscles may make the patient actually feel worse until they are able to find, or are given, new references, and can meaningfully use them.

The concept of using the floor for support, neurologically-speaking, is not new to PRI.  The right arch and left heel are some of the first references taught in PRI to help gain and maintain PRI-defined neutrality.  In PRI Vision, the basis for this concept is taken from AM Skeffington’s (the father of behavioral optometry) description of vision that was written in the middle of the last century.  In it, he states that every 250 milliseconds, a process takes place that begins with coming to balance with gravity, uses information about the space around you from the eyes, and results in vision as the “emergent” from the process.  In other words, how our vision behaves has to start with our body (and really, the brain), first dealing with gravity.  The space around you is literally the air and objects around, under, and above you.  It then stands to reason that the better we can deal with gravity the right way and make sense of the space we are in, the more efficient and less taxed our visual process can be.

Ideally, we should be able to balance on one side without over-extending the body, unconsciously using appropriate references, and maintain this while freely moving our eyes around to any desired object; this demonstrates good ability to center.  When a patient is overusing the visual system to do this, changes in the visual process happen.  It could be that they tend to “fixate”, or stare, at one point to balance, as in the above example of staring at the floor.  A more commonly-seen change in PRI Vision is that the patient can’t alter the way they are attempting to center themselves until we alter the space around them through lenses.

What does this mean in terms of treating patients everyday?  We don’t claim to have all the answers.  But we do believe that the more aware a patient is of the floor, especially on the left after an activity that helps them become neutral, the more likely they are to maintain that neutrality.  Conversely, if they have poor floor awareness, or it’s not at least equal on the left to that on the right, you need to look further up the muscle chains for a descending problem.

At the top of all the chains taught in PRI, is vision.  Not every patient who needs PRI Vision intervention has poor floor awareness.  But if a patient is not able to find awareness of the floor, even if momentarily “neutral”, they will likely need PRI Vision intervention to see it differently, so that they may find the floor and keep it without challenging the visual process to do so.

 

As Always,  Keep Moving Beyond Sight!

Dr. Heidi

PRI Vision & Computers–Part Two

As promised, this second part will teach you how to select the right chair for using a computer (or for any prolonged seated activity) and the best position in the chair to keep your body and eyes happy and tension-free!

Let’s start with chair selection.  Here are the things you want in a good chair (see pictures below as well):

  1. The ability to feel your mid-back (the area right under your shoulder blades) hit the chair back without the backside of your calves or knees restricting you from sliding back “into” the chair.
  2. Adjustable arm rests.
  3. An opening in the bottom of the chair back to accommodate your posterior glutes and hips.
  4. A seat that is semi-firm with a rounded edge at the front of the chair seat.  Padding is fine, it just needs to be firm so you don’t “sink” into the middle of the seat.
  5. Height adjustment so that your knees are at the level of your hips, or slightly above them with both feet flat on the floor.  For some of us shorties, this necessitates the use of a block or a taped-up phone book under the feet, otherwise the desk and keyboard tray is too high once seated.
  6. Adjustable seat back that tilts forward or back.

Chair w Arrow Body position in chair Short position in chair

“What if the chair I have doesn’t match your description and my company won’t spring for a new one?”  

Here are a few tricks to make the best of what you have:

  • People 5’4″ & under (like me!) are shorter than what most chairs are designed for.  The telephone book or block under the feet will be a must for most of us.
  • The seat depth (from front to back) will likely also be too large for the knees to clear the front of it and hang down freely.  Use a soft pillow, wider than your torso, positioned so that the top edge of it hits near the bottom of the shoulder blades.  This substitutes for having chair contact at this area as in #1 above, and you should feel as if it’s just a padded chair back with contact in the same area.  Don’t use a lumbar “roll” or “support” that keeps the bottom part or middle of your back pushed forward!  Placed properly the pillow should allow you to slightly round your back while your hands are on the keyboard or mouse.
  • Taller than ~5’8″?  Your chair challenges will be different, and slightly harder to use substitutions since you can’t add more size to a chair easily.  Consider moving the keyboard to the desk top surface from a lower-placed tray to give you more room to bring your chair up high enough.  A chair that has extra adjustment options for the back may help give you a little more useful room in the seat, or one that is designed larger than average is ideal, but these aren’t your typical task chairs available from mass retailers.  Find a local office furniture design firm who orders from more commercially-targeted  manufacturers.  A good designer will be able to steer you in the right direction to meet your body build, and often offers a chance to try the chair in your work environment before ordering one.  (Ours even dropped it off and picked it up for free pre-sale!)  You’ll pay ~$300 or more for a good one, but it will be well worth the investment when you don’t need weekly massages to undo all that tension!

Ok, now that you know what to start with, let’s get to how to use it!

  1. As you sit make sure your mid-back is in contact with the chair back and both feet are flat on the floor (or phone book) with the knees at or slightly above the level of your hips.  If you have on heels, kick them off under the desk so you can feel your feet on the surface under them.  Flat shoes don’t need to be removed.
  2. Round your back slightly without losing the mid-back contact point from #1.  Here’s how:Finding Ribs
  • Put both hands firmly on the bottom of your rib cage.  Don’t push at first, just feel your ribs with your hands.  You want to be able to find the edge of your ribcage curving downward under your fingertips when you push them in slightly, as if giving yourself a “squeeze”.
  • Once you have your hands placed and are not pushing in with your fingers, lean back with your shoulders so that Ribs Upyour back arches.  You should feel the edges of your ribs under your fingertips (without pushing hard) sticking outward and you will see your hands move up slightly as you lean back.  Your low back will move forward as you arch.  This is too much extension of the trunk, based on PRI principles, and is the very position you don’t want!  Ironically, this is the position most lumbar supports will put you in!                                            RJibs Up Side View
  • Now slowly lean forward with both shoulders.  As you do this, begin talking, so that you are encouraged to breathe Shoulder-Hip Alignmentcontinuously as you come forward.  (Say the alphabet, for example.)  You should feel the top half of your back moving forward, and the bottom half moving slightly back, so that your hands are moving down and the edges of your ribs are harder to feel under your fingers.  Your shoulders should now be slightly behind your hips, or close to it.  This is the optimal position and should be the goal!Shoulders in Front
  • Once the edges of your ribs have disappeared from your fingertips without pushing in, keep going forward so your shoulders are farther forward than your hips.  Your mid-back will lose contact with the chair back while your low back will push into it.  You may feel your abs tighten up as you would if you were doing a “crunch” style sit-up.  Your rib edges should be hard to find, and may feel “hunched” over.  This is too far in the opposite direction of extension and doesn’t allow for proper head and neck support.
    Leaning in is typical for many computer users, especially if they subconsciously over-focus their eyes.

    This is what leaning too far forward may also look like.

    Body position in chair

  • Go back to the optimal position described in the second bullet.  You should be able to keep mid-back contact, let your shoulders relax, and breathe easily here.  If you can’t get this with a little practice, or it’s not comfortable, find a PRI-minded therapist or trainer in your area (online at posturalrestoration.com or call them if you don’t find one with the “locate” tool.  They are happy to help!).

Our third and final installment coming up will give you some activities to add to your chair time.  These will help to combat the natural tendencies we all have when we sit for long periods that promote tension.

Until then, Keep Moving Beyond Sight!

Dr. Heidi

Postural-Visual Integration, Phoenix, AZ, 2013

Postural-Visual Integration 2013, Phoenix, AZ

 

I recently had the privilege of accompanying Ron and Dr. Heidi to Phoenix, Arizona to teach our Postural-Visual Integration course at the East Valley Spine and Sport Medical Center.   We want to extend a sincere thank you to the staff of East Valley for allowing us to invade your office for the weekend; you were nothing short of a gracious host. 

We had a wide array of attendees at this year’s course, ranging from physical therapists, students, and chiropractors as well as a handful of trainers from the Arizona Diamondbacks!

Thank you to all who attended, I know it was a long couple of days but leave it to Ron and Dr. Heidi to keep things entertaining while filling our heads with the wonders of PRI Vision!

Please check out http://www.posturalrestoration.com for all of our upcoming PRI Vision courses in 2014, and as always….KEEP MOVING BEYOND SIGHT!

PRI Vision & Computers–Knots & Tension & Stress, Oh My!

Computers are an integral part of most people’s lives today. This isn’t news. What isn’t widely known is how using your vision for the computer is quite possibly the very thing making the extensor muscles of your body work overtime, causing tension, pain, poor performance, or even hampering your upright physical activities. Here’s the lowdown on the visual system’s role in this:

  • Focusing (eyedocs call this accommodation) on a close target, such as a computer screen, is required for the majority of people to make the words on the screen clear.  When the muscles inside the eye are stimulated for this close focus, there is an associated tensing of many muscles in the head and neck.
  • The closer you are to the screen, the more the muscles inside the eye are stimulated to work harder, exponentially, to make it clear.

    Leaning in is typical for many computer users, especially if they usually over-focus their eyes.

    Leaning in is typical for many computer users, especially if they subconsciously over-focus their eyes.

  • If your vision isn’t clear, and you must strain to either make it clear or to see despite the blur, the extensor muscles of the head and neck will tighten up.  For all you PRI junkies out there, this could produce a positive TMCC (Temporal Mandibular Cervical Chain) pattern.  For the lay person, this means tension in the upper shoulders, neck, jaw, and/or head.

    This position could be due to bifocal use, eyestrain, or the neurological love for extension tone!

    This position could be due to bifocal use, eyestrain, or the neurological love for extension tone!

  • Many people over 40 need bifocals to see things that are close.  No-line bifocals (aka progressives, multifocals) are great for cosmetics, but can be detrimental at the computer if not designed for this purpose.  Often too much head movement, especially tilting the chin up, is needed to find the “sweet spot” in the lens to see the computer screen, and this “spot” is usually not very large because computer use isn’t the primary purpose of the lens design.  Tilting or constant head movement to “search” for this spot will do the same thing to the muscles of the head and neck as in the last point.

    Common position for bifocal user.  Hello SCM activity!

    Common position for bifocal user. Hello SCM activity!

  • Any close up task that requires mental concentration is more likely to have you “focusing in” on the details.  This isn’t referring to clarity of words on the screen, but rather to where your visual attention is directed.  Look at your screen and see how far out to each side you can “notice” other things in your peripheral vision, such as a picture, a calendar, a window etc.,  without moving your eyes away from the screen.  If you frequently have difficulty maintaining subtle awareness of objects in your side vision, you are more likely to tighten up the head and neck muscles.  Clinically, we have also observed over-focusing on the details inhibiting proper diaphragmatic breathing!—Do you yawn a lot???

If any of the above things are going on during a typical day, it will be tough for someone to be physically comfortable and their most productive at the computer.  Less obviously-associated symptoms include difficulty concentrating, fatigue, foggy thinking, and trouble keeping your place on the screen/in a document.  Worse yet, it will make it nearly impossible for someone to stay “neutral” in the PRI world, even once they are done with their screen time and get physically active.  This is because overuse of the neck muscles directly impacts the spine and trunk below it, even after you stop the activity.  If you don’t know what “neutral” means, trust me you want this!!!  It means much more than this, but simply put there is no extra tension in muscles that shouldn’t be there to hold yourself in whatever position you are in:  sitting, standing, etc.  (visit http://www.posturalrestoration.com for more info)

How do I avoid this?

  • I recommend that the computer screen be no closer than arm’s reach away (with palm flat on the screen).  Farther is better in most cases!
  • Set the height of your screen so that about 2/3 of the screen is below eye level.  Some people like a little more, some a little less.  Move it around and see where BOTH your neck and eyes seem to be the most comfortable.  If the eyes and neck aren’t comfortable with the same height, you probably don’t have the right lenses on.

    Notice the increased eye-to-screen distance.   The neck and eyes will love this!  The screen could be a bit higher for optimal positioning.

    Notice the increased eye-to-screen distance. The neck and eyes will love this! The screen could be a bit higher for optimal positioning.

  • Wear the right optical correction for the task.  For some, this might be the same thing you normally wear, even nothing at all.  For bifocal users, eliminate the need to search and tilt the chin up by getting computer-specific lenses.  Your optometrist can help you with this….just ask them!  There are also patients who can see the screen clearly (and some who can’t), but their optometrist can tell they are straining to see it with a few probing tests; in this case, computer lenses may be recommended to make it more efficient for the visual system to look at a screen all day.  This last type of person is most likely to include those who have great vision and have never had an eye exam because they don’t “need it”.
  • Not all eye exams include a look at computer vision.  Bring it up!  If you don’t have an eyecare provider or one who will do this for you, go to http://www.covd.org and search for one in your area.  These docs tend to look at more than just seeing clearly far away.
  • Place objects you can periodically be aware of in your side vision, especially on the left side.  Check in with yourself a few times an hour to see if you can still see them without moving your eyes from the screen.
  • Take visual breaks.  For one minute every 30 minutes look at something far away:  out a window, across a large room, anything farther away than 15 feet preferably.  Stuck in a closed-in cubicle?  Close your eyes and imagine a relaxing image that includes lots of wide-open space:  a beach, the view from a tall building or mountain, or an open field are good ones.  Whether looking somewhere real or imagined, let your body and eyes relax and slow your breathing.  Don’t focus on far away details, just take in the scene!  If your distance vision wasn’t clear when you first looked far away, it should get better with this.

These tips will go a long way to making a happier, screen-loving you.  In the next part, we’ll look at body positioning in a chair to provide the proper base of support for the shoulders, head, neck, and eyes to deal with the demands coming from a screen.

Keep Moving Beyond Sight!

Dr. Heidi

Blurry Vision and Leashes–Re-publishing A Blog From January 2011

Blurry Vision and Leashes?

I’ll have to admit when I first started seeing patients with Ron in the clinic I was having a little trouble mentally with the concept of blurry vision. As optometrists, we are taught to make people see clearly. Let’s face it. The number one reason why a patient comes into our office is that they want to see more clearly than they currently do. If you are the doc who gives them 20/15 vision, which means they are able to discriminate details smaller than the “20/20” standard you hear about, they are happy. Think back to experiences you have had when you picked up your new glasses or contacts and put them on. Many of us, myself included, have probably even said “Wow, I didn’t realize what I couldn’t see” to ourselves.

Coming from a background in behavioral optometry, I was already comfortable with prescribing lenses for function. My own two children use lenses for reading that don’t change the clarity of the words, but allow their visual systems to do near work more effortlessly. However, for the patient who has headaches at the computer, but can see clearly, it is hard to make them understand why a different prescription for computer use can help their headaches. The vast majority of us believe if our vision is clear, then there isn’t anything that warrants change. As an optometrist, you must ultimately satisfy the patient’s desire for clear vision.

So when I first started seeing patients with Ron, and the lenses the patient needed to achieve PRI-defined neutrality made their vision blurry in the distance, I was very nervous. Not that I didn’t know we were doing the right thing for that patient, because I did believe it. Whole-heartedly. The problem was that the traditional eyeglass and contact prescriber in me was concerned about how the patients would react to their new way of seeing. Would they keep wearing their new lenses, allowing them to progress through their PRI program?

Now, after five full months of seeing patients a couple days each week with the Hruska clinicians, I am almost more nervous when the lenses that allow the patient to be neutral also allow them to see relatively the same as with their current lenses. Why? Because we know more now than we did five months ago. We’ve had the opportunity to see patients do what humans are so good at doing: adapt! What adaptation means, in terms of what we are doing, is that they stay neutral for a period of time with the new lenses, but then they either go back to their old pattern or perhaps a less severe version of that pattern. For some, that period might be two months; for others, it might be two weeks. These patients are generally compliant with program activities, exactly as they were instructed. The point is, something allows them to get a hold of the old neural pathway and old muscle memory associated with the old pattern. That something might be as innocuous as picking up their violin for a few practices.

This is what has led us to develop some variation on when we tell the patients to wear their “training” glasses. Your patient’s wearing schedule will reflect a few things. If we had to make a dramatic change to their prescription to get them neutral, likely we will have them wearing the glasses only for physical activities. We may even tell them we don’t want them to wear them if they are going to look at things farther than 15 feet away. This is where the concept of blurry vision is most critical. Some patients are so strong in their old pattern, that any time they engage far away vision, they lose neutrality. So, we start with them trying to maintain neutral in a smaller area, so distant vision doesn’t engage. As they improve and are able to hold that neutrality given those limited conditions, we will continue to extend their range of clear vision out further, slowly progressing them towards more clear distance vision. We affectionately refer to this slow increase in visual space as a “leash.”

There will be patients that are using their new prescription full time. They may habitually not wear any correction, or maybe the new correction blurs their vision a little, but not enough to have them reject it. There are others that require that full-time reinforcement at all distances of visual space to be able to make a change. How do we know which ones can handle which option? Again, we are learning an immense amount, and there will certainly be times that our best-educated predictions are wrong. We are, after all, humans trying to predict the neurologic behavior of other humans. Not exactly what we’d call an “Exact Science”. Yet you can rest assured that we are constantly re-evaluating our approach and taking advantage of every learning opportunity a patient’s experience gives us to provide improved, more predictable patient outcomes.

What I have come to realize is this: How can I expect someone to do something different if I allow them to have relatively the same visual reaction? There are always exceptions to these “rules”. Lazy eyes, high amounts of astigmatism, and strong Functional Cortical Dominance, which we will talk more about in the spring Integration Course, are all variables that make the need for visual change that much stronger. As we peel away the layers of some of these patterns, we are finding other sometimes undiagnosed strong visual patterns that will have to be addressed through more vision-specific training.

We do our best to make sure patients leaving the clinic understand we are trying to provide vision that forces them to develop different neurological and muscular patterns, not make them see more clearly. We have them identify a pain or tightness that is present on the day of their visit before we start changing lenses. That pain or tension is either gone or diminished when we have on our “final” prescription. We absolutely LOVE when a significant other accompanies the patient to their visit, so there is a second pair of eyes and ears to remember what changed for them in that treatment room. Reinforcement of those concepts from their PRI physical therapist is crucial.

The ultimate goal is to have the patient maintain neutrality regardless of what prescription they do or do not have on their eyes. To achieve that goal, it takes motivation, consistent repetition of program activities, patience, relatively blurry vision, and sometimes, even a “leash”.

Here’s to progress through integration!

Heidi Wise, OD

Originally Posted 01/20/2011 by Heidi Wise.