Postural Restoration Institute Course Review
I recently had the opportunity to attend two courses from the Postural Restoration Institute – Myokinematic Restoration and Pelvis Restoration.
The basic premise of the system that is taught by the Postural Restoration Institute is that the body is asymmetrical and, in order to optimize human function, we need to try and restore as much symmetry needed in order to have balanced reciprocal function (while appreciating the asymmetries of the body and acknowledging that we will not change them). Basically, we have a liver on the right side, the crural attachments on the right lumbar vertebrae are thicker than on the left, the right lung has three lobes while the left lung has two, etc (we can go on and on with these sorts of asymmetries), thus we tend to orient ourselves over the right leg which places us in a pattern of right mid stance, referred to as a Left AIC.
Left AIC
The main pattern discussed and the backbone of their system is the Left AIC (short for Anterior Interior Chain). The Anterior Interior Chain is a chain of muscles which connect the torso to the knee and consists of the diaphragm, psoas, iliacus, TFL, vastus lateralis, and biceps femoris. We have two AICs in the body, one on both sides, however the Left AIC tends to be more dysfunctional than the right. Additionally, individuals may find themselves in other patterns but underneath those patterns is always a Left AIC due to the natural asymmetry of the human body as discussed above.
In this Left AIC pattern the main findings include things such as:
- Anterior pelvic rotation on the left
- Increased hamstring length, tension, and tone on the left
- Pelvis rotated to the right side
- Right ischial tuberosity sitting lower than the left
- Left femoral head is not received as well by the acetabulum as the right is
- Right side is more in a position of adduction, internal rotation, and extension
- Left side is more in a position of abduction, external rotation, and flexion
- Decreased trunk rotation to the right side
- Decreased right apical expansion and left diaphragm opposition
- Increased left rib flare (poor left zone of apposition)
- Decreased left mediastinum expansion
All of these things are actually “normal” and are due to the natural asymmetry we all posses; however, some people – with proper training – can control this position better than others and thus perform at a higher level. Other individuals may not control this position well and end up compensating in such a way that they themselves in a position of PEC – short for posterior exterior chain – where they exhibit many of the things above on both sides, bilaterally.
PEC
The Posterior Exterior Chain consists of our latissimus dorsi, QL, Posterior Intercostals, Serratus Posterior, and Ilicostalis Lumborum.
Being in a PEC position is characterized by attributes such as:
- Stiff looking gait mechanics
- Bilateral hyperlordosis
- Both hips in a position of flexion, external rotation, and abduction (people tend to walk with their toes out)
- Butt gripping (tight gluteus maximus bilaterally)
- Flat and stiff thoracic spine
- Bilateral compression of the SI-joints
- Sagital plane dominant individuals who have lost optimal function in the frontal and transverse planes
- Pelvic floor in a descended position, bilaterally, causing the muscles of the pelvic outlet to be stiff and inflexible leading to issues with constipation
- Poor zone of apposition bilaterally
- In a state of hyperinflation, lacking the ability to exhale and allow the diaphragm to dome up
Goal of PRI
The goal is to use a battery of tests to determine what sort of position the individual is in and then what type of control they actually have. To do this, the Postural Restoration Institute has a number of tests – some are tests of position while others are tests of function – to help understand the person in front of you and make informed decisions about exercise prescription. To take it a step further, the tests are also used, in an algorithmic sort of way, to differentiate between individuals displaying one of these patterns versus individuals displaying one of these patterns but considered to be “pathological” and displaying a certain amount of ligament laxity – referred to as a Patho Left AIC or Patho PEC. This information further drives exercise choices as those that are pathological may need a different set of exercises or exercise regression to ensure they are performing the movements in the right position and feeling the correct muscles working.
PRI can get extensive with the exercises as they have over 100 in their catalog although there are a few exercises that would be considered “big money” exercises for each of the possible patterns one may be in. If you understand the patterns and use the testing approach effectively you will understand which structures/muscles you are looking to facilitate and which you are looking to inhibit and can pretty much use any permutation of the “big money” exercises as long as they achieve the intended goal and improve the testing when you go to re-test, which should be done frequently to know if what you are doing is working and if you are helping re-position the individual.
Similarities with other Approaches
Whether it is PRI or any other system (DNS, FMS/SFMA, Janda, Osteopathic approaches, etc) there should be some similarities in the message as all of the systems are dealing with the human body. It is the similarities between all these things that I care the most about because it helps me see the big picture and be aware of more things when I look at an individual.
One thing PRI does is go heavy into the anatomy of the body with regard to how muscles function and they do a good job of differentiating between which attachments are moving and which are stable. For example, we can have femoral acetabular rotation (a femur rotating on a pelvis) and we can have acetabular femoral rotation (a pelvis rotating over a femur). This is similar to the idea of punctum fixum and punctum mobile in the DNS methodology. While some may consider looking at things like this as being a bit excessive, I truly believe that understanding these concepts can be extremely helpful to understanding function and programming exercise.
PRI has a large focus on breathing and talks extensively about the “zone of apposition” (ZOA) – the aspect of the diaphragm that apposes the chest wall. The ZOA is influenced by the position of the rib cage. When the rib cage is flared upward, ribs in external rotation, the ZOA is not in a position to function and allow for proper diaphragmatic breathing. In DNS this same position is referred to as on “open scissor position” where the rib cage is angled upward and the pelvis is angled downward (anteriorly tilted), causing increased erector spinae tone and a lengthened abdominal wall which posses a high amount of tension. Individuals with an inefficient ZOA or the open scissor tend to be more upper chest breathers, stuck in a hyperinflated position, and recruit the neck musculature (SCM, Scalenes, Levator, Upper Trap) to assist with respiration.
I see a bit of an Osteopathic influence in the PRI system which is cool because I have read a lot of Osteopathic texts. The whole approach to re-positioning the pelvis in PRI is similar to self Muscle Energy Techniques where the individual is using muscular force to drive the pelvis into a certain position (which is great because you don’t have to put your hands on the person for these techniques to be useful and can allow the client to feel empowered by performing the activities on their own). The interesting thing is that the common pattern in PRI, the Left AIC, is opposite that of the common pattern in Wolf Schamberger’s text, The Malalignment Syndrome, which states that everything is happening on the right side (right pelvis in anterior rotation rather than the left) and this is similar to some of the other Osteopathic things I have read in the past. The instructor gave some answers as to why this is and in the end it comes down to a visualization thing as most of the other approaches were looking at anatomical landmarks with the person either supine or prone on the table and because of this they can be flawed as anatomical landmarks can change when someone lies down on the table (Schamberger does talk about some of these changes in his book on pgs. 43-44). Thus, PRI recommends tests of position and function rather than static tests of anatomical landmarks. The instructor of the course also talked about how the Muscle Energy Techniques used in those Osteopathic approaches achieved a similar result a lot of the time, even though their understanding of the position was incorrect, because they were activating the correct muscles to drive the pelvis into the correction position. Who’s right? Who’s wrong? Does it really matter? At the end of the day the goal is to make a positive improvement and if you did something that had a positive influence, even if your explanation or thought process wasn’t 100% correct, I don’t know if it matters all that much. Another thing that I would add is that the Osteopaths discussed breathing and the autonomic nervous system pretty extensively so perhaps their holistic approach achieved many of the similar results that those using PRI achieve. Regardless, there are a lot of similarities between these two approaches to pelvic movement and correction which is interesting to look at and be aware of. The Osteopathic similarities with PRI also show up with regard to the discussion on the diaphragm and viscera as the Osteopathic techniques on visceral manual therapy/massage discuss similar relationships between the diaphragm and the liver on the right side and the diaphragm and the spleen on the left.
Finally, the PRI patterns, particularly the PEC, is where I see some similarities to Janda and Travell and Simons. This pattern is very similar in appearance and function to the Upper and Lower Crossed Patterns from Janda. Many of the muscles which are discussed as needing inhibition in PRI (and in Janda) are also those that are either needed to keep us upright throughout the day (anti-gravity muscles) or those that help assist with respiration when the diaphragm is not functioning properly. So, it makes sense that things you want to inhibit in some of these patterns are the lumbar erectors (we live in a world of extension) and the glutes (particularly in the PEC pattern). Additionally, the vastus lateralis is a muscle which is part of the Anterior Interior Chain and one that can function significantly in these patterns to help provide stability. It comes as no surprise that this muscle is also one that is frequently riddled with trigger points, particularly in the lateral side under the IT-band (which lies over the vastus lateralis, biceps femoris, and is influenced by the TFL – all three muscles which are part of the Anterior Interior Chain).
Integration & Conclusions
I have enjoyed the courses thus far and look forward to taking more of them. I think that they underpin things I already do in practice very nicely and can fit well within the FMS model as another tool that can positively impact the results in some of the tests. Also, I have found that when there are a number of things going wrong in the FMS using some of the PRI approach can be helpful to reposition the individual and then retest to see what sort of improvements have been made. I have been using some of the exercises in my own warm ups and in the warm ups of a few people I have been working with (based on what we have found in testing) and the results have been very positive.
I don’t think any one system has all the answers and I don’t think any system will ever have all the answers as there are so many things that influence the body and so many things we don’t quite know. What I will say is that I really enjoy when different philosophies line up and share many similarities. The PRI approach is one more tool in the toolbox to help understand human function and their courses are some of the most fun I have had during a con ed course in a pretty long time.
patrick
patrick@optimumsportsperformance.com
21 comments
Patrick,
Great review and comparison of information. Of particular note was one line in which you mentioned self-MET exercises that were similar to the PRI realignment exercises that empowered the client because they can perform them on their own. This I find to be an important case in regards to client or athlete retention, perhaps owing to the fact that once they can perform this exercise successfully, their confidence will increase significantly.
Beyond the obvious positive results you have seen, I’m wondering how significant PRI will come to be viewed, very similar to how self-myofascial release is now an often precursor to many strength and conditioning (and fitness overall) programming, as it foam rolling can be performed by a large group with a simple tool.
Thanks for the review Patrick.
Here’s a big question I have about PRI. If correcting posture or “position” is such a critical factor in resolving pain, then why is it that most studies usually find no correlation between posture and pain? There have been studies looking at the angle of the sacral base, degree of lordosis, degree of kyphosis, amplitude of the spinal curves, and most find no correlation with pain. Scoliosis studies are similar to my recollection (no correlation unless the curve is huge).
Seems like quite a big elephant in the room. I watched the home courses so I had no chance to ask about this. Do you know if they have an answer for that?
As I was reading this Patrick, the first thing that stuck out for me was pelvic asymmetries such as rotation. I was about to quote Todd and his recent pelvic palpating article and here is commenting.
Big elephant in the room indeed.
Great, great review, Patrick. Thank you for taking the time to put your thoughts down. Todd, what did you think of the home-study courses?
Posture and position are two different things.
PRI does not have a traditional static postural assessment although it is mentioned and observed, it does not drive any decision making. Determination of position is done via the positional tests.
No one treats pain. The only time pain is mentioned at courses is in reference to common diagnoses (“SI pain”) with the description of mechanics underlying those diagnoses. The goal of PRI is to restore reciprocal movement.
Well done Patrick, great perspective.
I think Bill hit it on the head. The course is not really about posture (despite the name of the institute). It is more about position and then exercises to help maximize this position as it is normal to the human body. They don’t believe you can make the body symmetrical and that is not the goal.
Re: Pain
I’m not sure anyone has the answers when it comes to pain. Posture and pain don’t seem to correlate well, yes I think we know this, but in sport you certainly can have biomechanical overload of tissue and if working on position allows that tissue to get to a state where it can be unloaded and recover then that is a good thing. Additionally, with pain, the big player here may be the novelty of the exeecises that create a positive change in the person’s perception of their situation. Who knows? Something positive seems to happen and if the person gets up after doing some of the exercises and is pain free I wont complain and I guarantee that they wont either. I can sit around and hypothesize about it later!
patrick
I hear what you are saying Patrick. When I watch videos like this one though, even alignment and performance come into question no?
http://youtu.be/EAW87NsiGuI
Not sure what you mean by “come into question”. It isn’t odd to me that athletes have technical nuances that are unique to them (we see this in sport all the time). I think that is where you really have to make a decision about what to change and what to leave alone when the athlete is at the elite level. Sometimes it is a matter of leaving stuff alone when they compete or participate in their sport but in training (or with recovery interventions) you want to try and get them to a place where tissue can heal and not allow them to constantly overload structures. As they say, “good sport starts where good health ends.”
patrick
I take your point. By come into question I mean if a runner with the mechanics in the video shown can reach elite performance than correcting something that doesn’t look right or feel right to an outside observer may need healthy skepticism.
For sure, Byron, I don’t think there is any one, single way to do things. I think the approach that PRI has is interesting but I do also respect that in athletes you should not try and mess with something just because it doesn’t look right to the observer (as the saying goes, “Does their running style bother them as the runner or does it bother you as the observer”). I would never suggest that anyone should forgo skepticism with this stuff either. I am skeptical of everything (including myself) and I try and remain as middle of the road as possible without swaying to far to the right or left.
patrick
Patrick, nice introductory summery of PRI! Did you work with someone in PRI to write this? You did a great job for only attended two PRI courses and I am so glad to hear you are going to attend more courses.
I’d like to clarify a few points for the readers. One of the main patterns discussed in the two courses you attended is the Left AIC. However that is not the backbone of the system. It is important that the readers understand the poly articular chains of muscles PRI teaches are just ways we communicate objectively about patterns we see as reciprocal movement is lost in the torso and pelvis.
There are many polyarticular chains of muscle in the human body. PRI teaches those that are neuro-reflexsively influenced and involved in breathing and gait mechanics.
The backbone of PRI is at the core of the body “the diaphragm”. If you want to maximize athletic performance, coaches and trainers need to learn about how to maximize the diaphragm’s zone of apposition and one can be introduced to this by attending a live PRI Postural Respiration Course.
PRI is 100% application of biomechanics and anatomy. It is important for the readers to understand you can’t get this methodology by just attending 1-2 courses. And if you have only attended a home study – you surely won’t get it. Each PRI course builds off of the others. PRI teaches movement professionals the difference between FA and AF movement, GH vs. HG, and ST and TS which is just clinical application of muscle and joint anatomy, muscle action and muscle function.
Not sure if I fully understand the “elephant in the room” comment. But posture with PRI is not looked at as a product of “standing up tall”, like what most people think of when they hear the word posture or what studies may refer to as posture. Using a static postural assessment is an extrinsic or traditional approach to look at posture. As one learns more about PRI, they quickly learn to appreciate just gathering 4 views of posture (Face On – Back – Both sides (Right & Left) or palpating bony landmarks isn’t the best way to identify the resting tone of polyarticular chains of muscles affecting intrinsic alignment. Static postural exams tell you nothing about the cause of a person’s pain, discomfort, or tightness.
With PRI, you learn posture is about a product of the “position” of anatomical relationships and that it is neuro reflexively balanced and regulated on a neuromuscular & respiratory level. PRI clinicians believe dynamic posture or “position” needs to be evaluated, and a static postural assessment doesn’t tell us enough information. We need to know if there are limited functional patterns (or movement that is restricted in directions, planes, or normal boundaries of functional range, as a result of improper joint or muscle position). That is why we do the table exam and PRI tests. The objective tests tell us which exercises to pick to restore the limited functional patterns contributing to postural dysfunction or impaired movement patterns.
Pain is subjective and various person to person. Clinically, I see a huge correlation between posture, “position”, and pain, so I personally don’t need a piece of paper or research study to tell me there is a correlation. Objective measures always guide intervention.
PRI is osteopathy, emphasizing the interrelationships between structure and function and recognizing the body’s ability to heal itself with proper facilitation. MET tends to be taught localized and joint specific. PRI is more systemic, holistic, and neurologic. For example a good PRI practioner may use a left adductor and left ab wall to restore right shoulder IR and never touch the shoulder. Or a PRI practioner may with a dentist to help improve an asymmetrical bite pattern to restore right trunk rotation for an overhead throwing athlete.
As far as comparing to Wolf Schambergers or other osteopathic movement impairment patterns, it’s all a matter of perspective… http://posturalrestoration.com/blog/view/anterior-rotation-of-the-right-innominate-vs.-left…/
Please go to live courses guys – use the home study to help enhance your understanding of PRI after you get to go to a live course or get to work with a live PRI clinician.
Patrick, thank you for introducing and reviewing PRI for your followers!
Thank you for the write up, Julie.
I didn’t work with anyone to write my review.
patrick
Thanks for the responses to my original comment everyone, and sorry to drop out of the conversation. (I just remembered to check for responses to my original comment.) Here are some follow up points.
Bill, you stated that PRI does not treat pain and that pain is never mentioned in the courses. That is not my recollection of the two home courses I took. Ron and James frequently discussed ways in which posture (or position) can cause pain. The obvious message of the course, implicit or explicit, is that PRI interventions can help people with pain.
Further, a review of their website shows clearly that a primary intention of PRI is to treat pain. Almost every article describes how certain postures or positions can cause pain, and how PRI interventions can improve posture and reduce pain.
You also stated that PRI is not concerned with posture but rather position and that there is a critical difference between the two. I don’t really see the difference here. In fact, PRI materials usually use the term posture instead of position, and also claim that faulty posture causes pain. For example, from one of their published papers:
“The focus of PR is on restoring faulty posture (or pathomechanics) believed to be a cause of complaints toward normal, rather than directing interventions toward the painful extremity or region of complaints.”
Although you are correct in pointing out that the PRI assessments are not done in a standing position, it is clear that they are meant to assess postural orientations that occur during standing, walking and sitting positions.
For example, Ron talked at length about the importance of a horizontal diaphragm and caudal rib position to create a ZOA for proper breathing mechanics. He also talked about anterior tilt, excessive lumbar lordosis and excessive extension at the thoracoclumbar junction as being indicative of a pathological postural pattern. Given the nature of these claims, why can’t we test them by looking at studies looking for correlations between measurements of posture and pain? (For example this one: (http://www.ncbi.nlm.nih.gov/pubmed/19028253) And if the weight of evidence is that there is no correlation, isn’t that a huge problem for PRI’s claims?
There may very well be an excellent answer to this question but I have not heard it yet. Patrick made the (obvious!) suggestion on FB that I simply send this question to the people at PRI and ask them for an answer. I will do that and get back to you all if an answer is provided.
Thanks for the discussion.
Todd – have you ever spent time with a PRI educator or been to a live course?
I can represent the institute and explain, we use PRI everyday to treat symptoms like pain. But symptoms do not guide intervention strategies, instead we use a battery of tests to understand triplanar orientation and position of polyarticular chains of muscle which affect the resting state of the sacrum, sternum, and sphenoid.
Posture is defined in PRI as:
http://posturalrestoration.com/about/what-is-posture/
The study you mentioned above is a one dimension look at posture. We don’t look at sagittal plane curves, that’s only one plane. We understand the dynamic relationships to how multiple systems work to balance one’s skeletal frame. Extension tone in the sagittal plane may affect the left half of the body differently than the right. Therefore, since triplanar integration interests us in achieving a state of neutrality, I do not feel that is a problem, nor a research study that interests me or many of the other PRCs/PRTs that represent the Institute.
I hope this helps. I encourage you to attend a live course or connect with a PRI clinician to see how we assess “posture”.
Hi Julie,
Thanks for taking the time to answer. A couple of points in response.
I have not taken a live course but I have taken two of PRI’s home courses – respiration and myokin. For those that don’t know, the home courses are basically films of live courses – 15 hours of video each, along with manuals describing PRI theory, assessments and techniques. So as far as theory goes, the home courses would appear to be the same as the live course (the cost is the same too.)
In regard to the study I referenced above, you state it is irrelevant to testing the claims made by PRI because it addresses only sagittal plane alignment, and PRI is interested in alignment of all three planes. I don’t find this convincing.
Isn’t it true that from a PRI perspective, a person with sagittal plane misalignment issues, such as anterior pelvic tilt, increased lumbar lordosis, extension at the TLJ, excessive kyphosis, excess cervical lordosis and forward head position would be deemed to be at greater risk for musculoskeletal pain than a person with excellent sagittal alignment? Hruska makes numerous claims about the detrimental nature of all these sagittal positions, and in his Value of Blowing Up a Balloon article (which I liked), he focuses on sagittal plane alignment issues as being key drivers of respiration mechanics. In fact, to support his arguments he mentions a study finding a correlation between the degree of lumbar lordosis and chronic pain (but he fails to mention the many other studies where no correlation was found.)
Second, even though the study I cited addresses only sagittal plane issues, there are other studies where researchers failed to find significant correlations between transverse and frontal plane asymmetries and pain. For example, this study found that leg length inequality does not correlate with pain.
http://www.ncbi.nlm.nih.gov/pubmed/6146810.
Wouldn’t leg length inequality create the kind of pelvic asymmetry that PRI claims is a source of chronic pain? Put another way, if PRI is correct in its claim that pelvic asymmetry is a driver of chronic pain, then why is it that people with leg length inequalities do not have more pain than other people?
My brief review of the studies on scoliosis show that it appears that there is at least some evidence that people with scoliosis have more pain. However the evidence here is controversial, and some of the major reviews indicate that the link between scoliosis and pain remains unclear.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2938676/
These are people with huge and obvious asymmetries from side to side. If the research is still not clear that these cause a problem, then why should we spend time trying to correct minor asymmetries that are barely visible without sensitive tests?
From my perspective, these are completely reasonable questions that came to my mind almost as soon as the course started. I am not asking them to be argumentative or to prove a point, I am actually curious about the answers. I wouldn’t be surprised if there are good answers to the questions posed by this research, but I am surprised that you think people at PRI would not be interested in the research.
Todd,
Great stuff, thanks for posting the articles! These are all good questions and things that often float around in my head as well. I continue to be skeptical about all this stuff while also trying to appreciate the mysteries of the human body and the fact that we don’t know everything (and probably never will).
One thing that I do find interesting is that regardless of whether or not posture correlates with pain I am fascinated by the number of patients/clients who do actually improve using these methods (or methods from any of the other systems out there). I think one thing with regard to the postural/structure arguments is that people still have to move around and, while pain is a perception from the brain, we can still move like crap (especially if we move often and at high velocities like people do in sport) and increase the amount of biomechanical overload to tissue or joint structures leading to greater amounts of nociception which then changes motor programming and our ability to function optimally and ultimately can create greater amounts of central sensitization and an altered sense of reality, so to speak. With some of the movement based systems, by choosing exercises that are non-painful and non-threatening, perhaps the biggest win is in the brain (and less in the posture itself) as the brain senses new, novel stimuli which can allow it to begin to remap itself and get a sense that “things aren’t really that bad and I can actually do some stuff without pain”.
The other interesting thing that I find with all of this is that the confidence that one has in their therapist is highly important to the result that they get in their treatment. Anyone who invests considerable amounts of time in learning a system is clearly passionate about that system, professes its benefits openly and with great enthusiasm, and understands that system very well and can work its ins and outs with ease. This allows the client to feel comfortable with the therapist and feel that, “everything is under control (s)he has got this”. That is another huge win psychologically when dealing with those in pain.
Finally, you have to have somewhere to start when working with a client. If we just sit around and say, “none of this stuff matters”, then where do you begin with your treatment approach? I suppose you could say you being with the brain but really the whole goal is always to influence the brain no matter how you skin it. Whether you do that with words or with your hands or with your exercise selection, you are constantly trying to influence the brain to produce a favorable response. I find that some individuals argue about certain approaches but their argument isn’t so much in the approach itself but rather in how that approach is explained to the client. What all of these courses do is provide you with a system, some sort of starting point. Whether it is PRI, DNS, SFMA/FMS, McKenzie, Rolfing, Kinesis, etc…They give you an initial way to look at the individual, make some sort of observation and gather objective information and then begin your approach to influencing the person’s brain. How you explain it to the person I guess is up to you.
While I try and remain skeptical, on the fence, and “in the grey” towards all approaches, not accepting things as totally black and white, and being open to everything I do think it is hard to completely eliminate or disregard the postural/structural model completely. It may not be the only thing that people need to look at (which I think has been the main focus of people over the past few decades) but it is a piece that should at least be acknowledge, in my opinion.
patrick
Hi Patrick,
Thanks for the response. Those are all great points and I agree with almost everything you said here. And, for almost everything you said, it makes me want to go off on a tangent in about 10 different directions. So given my poor typing ability I will choose one or two at random ….
Like you I’m very interested in finding the common features of all these different systems – SFMA, DNS, PRI, etc. When I see that two or more groups have independently converged on a similar conclusion about the value of a certain posture or movement, it definitely gets my attention. With PRI, as you pointed out, I definitely see some things in common with things said by Mcgill, DNS, and others I respect. Good sign.
Hopefully the common effective features of all these systems extends beyond something as simple as providing novel proprioceptive input, verbal reassurance, movement through developmental patterns, and a confident and empathetic practitioner. If that is all there is to DNS and PRI than many of us are wasting time on these elaborate systems of assessment and correction, and should just instead be thinking of keeping it simple stupid. (maybe this is where Nuck Tuminello is coming from?)
Then again as you stated there is probably some extent to which these elaborate systems of assessment create confidence in the client as well as a logical framework for a practitioner to organize their work. Maybe some form of organization is useful regardless of what it is. And nihilism certainly isn’t the answer.
Another point – I’m not making any comments here at all about whether any of these systems work. It is very possible PRI other postural systems work fantastically. But for me I’m still left with questions about the mechanism of effect.
Further, I think that there are probably some very legitimate criticisms of the studies I posted. Here are two possibilities that occurred to me, and I don’t know whether they have any merit. First, it seems to me that even if two people describe the same amount of pain in the surveys or questions which generated the data from these studies, it is not necessarily the case the both of them actually do have the same amount of pain. All of us have a way of normalizing whatever experience we are used to. For the person who rarely has any pain at all, they are very likely to notice even minor aches and pains and might be more likely to report them on a questionnaire. Compare that to someone who routinely has numerous places that are chronically sore. I think their report and/or requests for medical assistance will be biased towards understating their degree of pain. For example, if you asked my 6-year-old daughter how much pain she was in last week compared to my 70 year-old mother, you might receive similar answers, even though I know Mom is hurting way more.
Also, one of the things these studies do not consider (afaik) is the level of function of the people. Someone with poor posture or biomechanics might have less pain than someone with great biomechanics and posture, but maybe that is because the person with good mechanics is out using their body to do stressful stuff they want to do, like run marathons or work 80 hours at their job. So even though these studies do not show differences in pain between two different people of different posture, perhaps this is because the people with poor posture scale back their activities to limit pain to an acceptable level, and people with good posture scale up their activities until they hurt at a certain level. Or not.
Thanks again for the chat Patrick.
Great points/observations about the studies, Todd.
I don’t think that the only common feature is that the systems provide novel stimuli. It would be silly to spend time studying such systems if that was all you needed to do. I do find, like you noted, that many of these systems have commonalities and, while the mechanism for why they may work is not understood (and may never be understood?), they all seem to barking up the same tree, or a similar tree, in their approach. In fact, they all should share a lot of commonalities if that same tree is the human body and they are all systems structured to treat human beings. So, I too find it interesting when I study these various systems, that I can connect the dots. I think that they way they work or how they work is an interesting thing to think about, consider, and keep in the back of my mind but at the same time I the main thing I care about is that they actually do work and produce some sort of favorable and measurable benefit that the client is aware of. I appreciate the literature/evidence and at the same time I am open to all possibilities of something work as the literature doesn’t seem to explain everything, takes place in a very controlled environment rather than the real world with real humans that are not protocols, and takes a significant period of time to get published and make firm conclusions.
patrick
Todd – I appreciate your curiosity and am assuming you have a genuine interest to learn more about PRI which I highly support and encourage. I am not trying to convince you of anything, simply put – you either have a desire to put in the time and energy to learn PRI or not.
As far as your first question “isn’t it true from a PRI….”. I would say no, just because people present in those postural patterns doesn’t deem them to be greater risk of pain. If the left half of the body presents in that pattern and the right half is in a different pattern then I would say yes, they probably have pain somewhere or some other kind of autonomic nervous system overload symptom (like dizziness). My goal with PRI is to try and get the neuromotor control of the left half of the body to match the right, not to reverse any or all of those postural descriptions you listed or treat pain.
Just to clarify, Hruska did not write the value of blowing the balloon article.
Second question “wouldn’t leg length inequality…” I would say no. I would not say PRI claims that pelvic asymmetry is the driver of chronic pain. I do not believe people with leg length inequalities have more pain, nor do I believe PRI has ever said or meant it in that context directly. Do we see some people in chronic pain with a LLD, absolutely. There is more to why a person who has a LLD may have pain, and we would dig into find out why that might be. There is usually a more proximal driver to why pelvic asymmetry exists. As an advanced PRI practioner, I do not set out to fix everyone’s pelvic asymmetry and I would rule out several things before I even acknowledge or care whether a person has a LLD. One would be to rule out if there is a mechanical ribcage restriction contributing to an asymmetrical ZOA and asymmetrical respiratory diaphragm function. We find different patterns as why a person may have a longer left leg or right. The patterns are what I would treat, not the pain.
Last question in reference to correcting minor asymmetries… as an advanced PRI practioner I do not try to correct minor asymmetries, nor do I believe the human body will ever be symmetrical. Without a doubt, PRI teaches you how to appreciate asymmetries, but I would not say we try to “fix” observable postural asymmetries. We recognize fundamental asymmetries exist in the body, and attempt to get our clients and patients into a state of “neutrality”.
Neutrality is our way of communicating about axial skeleton balance and reciprocal function. To define this state of neutrality we use objective tests and measures. The state of neutrality helps us communicate about neurological tone, respiratory function, and axial core control and mobility. Most importantly, neutrality objectively gives us a way to determine when there is neuromotor balance between the right and left side of the body.
Simply put, “I drink the PRI kool aid” and here’s why: I’ve been working in the industry for 15 years and my personal philosophies related to fitness, wellness, rehab, and athletic performance continue to evolve with a ton of post graduate trainings in various manual and movement techniques. Hands down, the PRI methodology is the best way to objectively assess and grasp an understanding of axial movement and control. I am a clinician and I don’t get caught up in research studies too much. I search for techniques that make objective changes on a test, re-test philosophy, and I have a genuine desire to achieve the best functional outcomes. I had a patient this week confess to maxing out his PT/chiro benefits in 2012 and then spent over $18,000 out of pocket for treatment by various physical therapists, manual and massage therapists, trainers, and chiropractors for a hip and back injury that responded to PRI in 6 sessions with me. He reports that this is the first time in over a year, he can swing a golf club pain free and play 18 holes of golf. He is hitting the ball farther with less effort than ever before. This guy had multiple chiropractors, trainers, and therapists before me, tell him he had a LLD, I didn’t, nor is that what I treated. I treated the respiratory mechanics and worked with a dentist to fix his asymmetrical bite – that my friend, is PRI. Additionally, this week I had 3 amazing athletes drive over 2-5 hours for me to evaluate them, not because of any other reason than I have a solid understanding of PRI and understand how to make the techniques stick. Before PRI, clients didn’t seek me out like they do now. All 3 had PTs, chiros, and trainers back in their hometowns. Why did they make the trip to see me? I can tell you more stories like this if you’d like because this is the empirical evidence that makes me “drink the kool aid”.
Obviously you need to find techniques that work for you, and PRI may or may not be a tool for you. It took attending and repeating multiple PRI courses more than I would like to publicly admit too to get to the level I am at today. Hopefully you can learn it better and faster than I did ? My point in sharing that is, you will not get a full understanding of PRI by just watching two home study courses. But it is a good place to start and I respect your good questions as most of us were there too at one point.
I do not feel the home studies are the same as attending a live course. The home studies are only introductory courses. The advanced courses are where more paradigm shifts occur.
I am finding a disconnect going on in the industry right now as some experts are getting into PRI and word is spreading on how effective PRI can be. Many people are buying the home study and going to courses in hopes to get just “2-3 nuggets to take away” or they don’t really want to learn the whole methodology because they don’t believe in one thing and rather take an eclectic approach to treating and remain skeptical to everything they set out to learn. That’s totally fine if that’s you – but I am here to say, if you go into a PRI course with this mentality, you are missing out! And frankly probably wasting your time and money. I consider myself an eclectic practioner and I pull from many tools to help clients. PRI has provided me a framework for biomechanical assessment of the axial skeleton which has been extremely valuable in making my assessment skills more efficient and effective, and helps me get to the root cause of the problem faster. I value this because I do not believe in chasing symptoms.
Because of the lack of understanding of the axial skeleton and holistic function, along with the initial way most of us are trained to look at segmental areas of the body, PRI is not easy for many to grasp right out of the gate. In general, most of our initial education is heavily emphasis on isolated extremities, and little is taught on the ribcage, diaphragm or axial skeleton. And little is taught on how to integrate systems of the body, we have a million of specialists out there for different isolated issues yet very few people understand how it all relates to each other. If I ask a group of professionals what is normal flexion/extension of the ankle, knee, hip or elbow we would get a pretty consistent answer. Now if I ask that same group what is normal flexion/extension of the spine, we will get much more controversy. Many people do not understand what is healthy axial flexion, nor do many people understand what is healthy diaphragm movement and how that affects the spine. Plain and simple, there is not a standard understanding of the “core” in the industry. Just a lot of people with many opinions. PRI has been the tool that has taught me an objective way to evaluate and treat the “core”. I understand now, better than ever, what healthy spinal flexion is, what over extension is, and how to generate optimal rotation and recruit the correct trunk muscles to do so.
The Postural Restoration Institute is young and still developing. But it’s important that people understand the principles and foundational science is strong, sound, and powerful. Ron Hruska is a brilliant, brilliant man and has more integrative education on the human body than any of us would probably ever care to attain. Most of the PRCs/PRTs, like myself, are more than willing to help teach and share their understanding with you if you reach out and ask for assistance as you embark on the learning process.
In closing, understanding PRI that will enhance your understanding of the “core” and the function of the axial skeleton. If you are an advocate for sayings like “proximal stability for distal mobility” or believe in helping athletes develop foundational strength and core control, I challenge your ability to assess and objectively measure axial movement and rotational power. If you are not assessing for a ZOA – you are missing out. The assessment of the diaphragm, ribs and ZOA is the backbone of the PRI methodology. When the ribs lose the ability to move in and out of the ZOA and the ribs lose the ability to reciprocally move and rotate, your spine and extremities develop asymmetrical patterns of muscle pull – insidious onsets of pain can emerge or inefficient movement patterns develop. When you lose the ZOA, distonia takes over the movement system and predictable neurological and biomechanical adaptation patterns become apparent. Extremities develop and function in asymmetrical fashions because the neuromotor control of the right half of the body and the left half of the body do not match.
Hi Julie,
Thanks for taking the time to make such a detailed response and relate your experience with PRI. It’s funny you mention Kool-Aid. I wanted to ask in my previous post if the only difference between the home course and the live one was the serving of kool aid.
Glad to see you have a sense of humor. And thanks again for all the information. If I have any more Qs about PRI after looking into it further, I will definitely send them your way.
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