Postural Restoration

[Jason Silvernail]

Oliver-
Thanks so much for coming here and engaging in a discussion with us. It shows some courage to come here given some of the previous posts, especially from me.

I disagree with most of what you've said, but look forward to engaging the debate in way where we can all learn.
More to come.

Jason.

[Jon Newman]

Hi Oliver,

I'm glad you've been able to find our humor humorous, (understandably) not everyone does. My first question is about this concept of idealized symmetry. Isn't lateralization of function considered normal development?

[ollyhall]

Lateralization normal development?

Hi Jon, you asked a question that we hear very frequently with Postural restoration. Yes, lateralization is normal, however regardless of if someone is L or R side dominant, the clinical presentation is the same, it does not switch sides to accomodate handedness. The L hip will still be more limited in adduction and extension and the R shoulder will be more limited in internal rotation.

[Jon Newman]

Hi Olly,

What clinical presentation are you talking about? Maybe I don't understand what it is you are fixing in the first place. Are people coming to you because they note a decreased hip adduction on the left and lack of internal shoulder rotation on the right?

[Luke Rickards]

Olly,

I once attended a lecture by a renowned professor of embryology. There were a lot of manual therapists in attendance interested in symmetry and he strongly made the point that asymmetry of structure and function begins at the very first cell division of a fertilised ovum and continues until the end of life. This is totally normal. As I am sure Jason will point out more thoroughly, there is very little to no evidence that asymmetry causes pain.

Luke

[Jon Newman]

It's comments like this from the Omaha World Herald (Dec. 17, 05) that get me to ask the question about lateralization

"The body has to work a certain way," Cook said. "What happens is in volleyball, they do the same movements repetitively over and over, so they develop patterns and their body gets out of balance."
For example, a right-handed pitcher who can't throw as effectively left-handed is unbalanced. Volleyball players develop similar asymmetrical tendencies. That imbalance manifests itself in pain and injuries, in fatigue and in concentration lapses, Hruska said.

The reporter, Dirk Chatelain, seems to have paraphrased that last part so perhaps he got it wrong but it makes it seem as if lateralization is being cited as a problem.

[Diane]

Hi Olly,

I have gotten a kick out of reading your Postural Restoration thread and peoples assumptions of what it is. I always appreciate hearing the views of other open minded therapists. I am a Postural Restoration Certified therapist and I’ll try to answer the questions you have asked.

Glad you could make it over to visit us here, on SS.
To indulge us here a little (for we are trying to clinically reason in a language that is new to many manual therapists), could you tell us what your system is about in terms of neuro function, neuro anatomy, neurobiology, neurophysiology, any one of those or any in combination? Especially the following points you make:

You mention that asymmetry is the “norm not the problem”. I believe this statement is a reflection of therapist’s frustration of not knowing how to treat the problem.

How can asymmetry not be a problem when it puts uneven loads on joint surfaces and muscles are forced to work asymmetrically and inefficiently?

Forced by what?

Postural restoration does not just say that you are asymmetrical, but that you will be asymmetrical in very specific patterns (ie a common compensatory pattern

If you can accept the existence of a common compensatory pattern, then it makes sense that any isolated segmental deviation from this pattern will necessitate excessive lengthening of soft tissue.

Why don’t we all hurt? Well, in many ways I think most people do hurt to a certain degree.. muscles will become overworked and trigger points will develop – as an example how many people have trigger points on their vastus lateralis or in the sub-occipital area – this is a form of increased tension that may not initially register as pain, but as physical demands increase these can very easily become tender and bothersome, maybe not at that specific location, but the increased tension in these muscles will necessitate altered function elsewhere in the body.

Back muscles are also likely to become tight and painful, as we are in a twisted state that puts the L hemidiaphragm in a poor position to work. In this position our spine is twisted, putting strain on facets, ligaments and disks and our back muscles work to lift our anterior ribs in an effort to compensate for the inefficient use of our diaphragm. Looking for evidence of a poorly positioned L hemidiaphragm? Check how many of your patients have a rib flare on the L vs the R.

How do we treat posture? Well there’s a lot more to it than telling patients to stand up straight. We treat the polyarticular muscle chain imbalances that pull us into a twisted common compensatory pattern.

if he could not show instant changes in patient ROM and strength (improved length tension relationship) people would not be buying into his approach so wholeheartedly.

Why do you think effects are "instant"? (I/m not disputing that they are, I'll take your word that they are.. but why?)

Postural restoration is an approach for therapists who understand that the body needs to be treated as an interconnected and interdependent being not on a joint by joint basis.

I can’t recommend Postural restoration classes highly enough. If you can take a course with an open mind and if you have a thorough understanding of anatomy and biomechanics, I am very confident it will alter the way you practice in future.

So I'd be interested in having all of the above translated into "neuro", if possible..

[nari]

Hi Oliver

Welcome to the site and a mutual opportunity to discuss separate views.

Asymmetry is evolutional and normal for homo sapiens; if we take the face or head, it is almost without exception, asymmetrical. Even the hair follicles grow in different directions on either side of the head. Would you suggest that this could cause problems? It's not weightbearing, but the head does sit on top of a structure that is very long and also makes considerable demands on subtentorial supports so it can defy gravity.
Another aspect which makes me rather uneasy is to go searching for causes of pain in a normally asymmetrical body. I wonder what picture of 'deformity' or 'abnormality' that gives to a patient.

Finally, there is no evidence that asymmetry causes pain. Not that I have noted; apart from some sense of pleasant change if one moves out of a very asymmetrical position, such as slumped for hours with a lateral shift which stresses the neural structures. But that is a temporary thing, which can self-correct once movement begins.

You have not (yet) mentioned the brain's role in pain generation. I am interested in what you think about that aspect.

Nari

[Barrett Dorko]

Yesterday I received an email from Raulan Young, another of the PRI Certified people and an associate faculty member of the institute. He also took my course in Twin Falls Idaho in January. I seem not to have had any impact on his thinking, so he joins a long list of therapists who for some reason refuse to fall under my spell. I told him that his words to me would be better sent here but he hasn’t yet taken me up on this so I thought I’d send this portion along:

“Our basic philosophy is the body develops neuromuscular patterns that are asymmetrical in nature and if these patterns go unopposed then dominant groups of muscles will develop and result in a pathomechanical problems.”

So I’m thinking, “Are we doomed?” Is this the kind of thing that happens just because we’re alive and don’t constantly attend to the plumb line? Is the creeping, insidious emergence of asymmetrical functioning some sort of modern day epidemic that the rest of us have missed somehow? How did our species survive all these years while existing in so fragile and (apparently) a non-self-corrective form?

I read this from Olly after I opined that asymmetry wasn’t actually a problem: “… this statement is a reflection of therapist’s frustration of not knowing how to treat the problem.” Well, we’re not going to meet in the middle on this issue. Painful problems have to have an origin, and, so far, this little detail seems to be missing from the PRI “philosophy,” which, by the way isn’t a theory in anything other than a vague sense. Can’t wait for them to clear this up.

I’m in New Jersey this week which perhaps explains my reaction to Olly’s comment that he “had gotten a kick” out of our apparent cluelessness regarding what PRI therapists think and do. Perhaps the explanations on their web site aren’t as clear as they suppose them to be, or perhaps we aren’t all that smart. But immediately to my mind came the scene from “Goodfellas” so brilliantly played by Joe Pesci:

“So, I amuse you? You think I’m funny? You think I’m a clown?”

Well, when Pesci asked these questions it was chilling. I can’t quite convey that here, so use your imagination.

[stregapez]

Welcome Olli, and thank you for your time here. Your post was interesting and also inspired some interesting questions and observations from other posters which I am hoping you might respond to. . As someone who is still becoming educated on this subject, and is somewhat "on the fence" regarding it I look forward to hearing more debate and hopefully gaining a little more clarity on the issue.

I would especially welcome a response to Diane's suggestion that you explain how assymetry, according to your school of thought, effects the nervous system, and why correcting assymetry would cause it to function in a more beneficial way (hopefully in some detail)

I was born in New Jersey, by the way, Barrett, though i could not say with any honesty that I have always wanted to be a gangster, though maybe for a few moments now and again

Dana

[ollyhall]

Why are changes instant?

Wow, I'm pysched that even though the thoughts I shared with you in an earlier posting have not been embraced, they have at least stimulated discussion. I appreciate all of the new questions you have sent me and I'll try to get to at least some of them. The question that is of most interest to me and I hope to you all is one that Diane posted:

Why are changes instant?

OK, there has been a lot of talk of humor on this thread, so why don't you humor me for a minute or two. I'm going to try to simplify to the greatest degree possible how postural restoration works. Earlier I metioned that it is common to see a rib flare on the L. Let's assume this is due to a poorly positioned L hemidiaphragm (due to rotational influences) that is not adequately opposed by the L internal obliques and transverse abs which then allows the L rib flare. Because our bodies are made up of polyarticular muscle chains, the L hemidiaphragm will not be affected in isolation. Below the L hemidiaphragm, the L psoas whose fibers overlap the L hemidiaphragm will also become more active, rotating the L hemipelvis anteriorly and rotating the pelvis to the R. With the L anterior ribs being in an externally rotated position there is less restriction of airflow into the L side of the thorax than the R (this is why Thixotrophy develops - please read these articles cited in the PRI refernces). With more air being directed to the L the R chest wall becomes tighter and the ensuing rib position puts the R scapula in a position that will not allow full R shoulder internal rotation (this explains the phenomenon of glenohumeral internal rotation difference that is being cited as a predisposing factor to shoulder injuries in throwing athletes).

OK, assuming everything I have said is correct (please also look at your patients and observe how many have a R shoulder that is lower than the L - again think uneven air flow and thixotrophy), would it not make sense to try to hold down the L anterior ribs either manually or by using a patients L internal obliques and transverse abdominal? This would in theory reposition the L hemidiaphragm into a Zone of Apposition (Paul Hodges and Simon Gandieva have done some wonderful work on the ZoA). With the diaphragm in a relaxed state the L psoas and iliacus (as the continuation of the polyarticular muscle chain) would also be able to rest so that the L hemipelvis would no longer be anteriorly rotated and the pelvis as a whole would not be rotated to the right. The repositioning of the L hemidiaphragm by aquiring a zone of apposition would also necessitate better expulsion of air from the L side of the chest and force more airflow into the R side of the chest. The increased airflow into the R side would alter rib and scapula position on the R side and therby allow full R shoulder internal rotation and also level the patients shoulders.

To aquire this position on a plinth is relatively easy and the challenge is to coordinate opposition muscles throughout the body to maintain this balanced state even when standing and indeed with all levels of activity.

This is about the easiest scenario I could come up with for you and this is by no means the only technique or exercise that is needed to correct patients alignment. I know it sounds too good to be true, and trust me when I was first introduced to the approach I was sceptical, and then when it was demonstrated I was perplexed to say the least. Having been able to study under Ron, it now makes perfect sense, and it is very rewarding to be able to have an approach where each time I evaluate a patient I can show them how their bodies move and then, either with exercise or manual technique I can instantly correct a positive Thomas test or restricted R shoulder internal rotation. It does wonders for HEP compliance when patients see and feel that the exercises are indeed affecting changes in their bodies.

For the interested and the sceptics alike, my best recommendation is to take a PRI course or try to observe a PRI certified therapist in your area so that you can see with your own eyes exactly what we do.

Olly Hall PT, PRC

[EricM]

But Olly, I have all of the above and don't hurt anywhere. What does that mean?

Eric

[Barrett Dorko]

Eric,

I'm guessing you just don't hurt yet, but I don't actually know why any of this stuff hurts yet.

Olly,

You aren't just going to answer the questions that "interest" you are you? That's not the way it works here.

[EricM]

Should we be able to predict where we will hurt based on this system, and how much, based on the degree of asymmetry present?
Can't help but sense a whole lot of fuzzy logic in PRI.

Eric

[EricM]

Olly,

You wrote that at first you were skeptical of PRI. What is it you were skeptical of and what changed your mind?

Eric