Welcome to our series on “Crazy Things In PT.” You find other posts in the series via these links – Crazy Manual Therapy, Stupid Exercises, Outdated Interventions. First, here’s a little note from the management:
These articles are intended to show some of the things currently done by physical therapists around the US and around the globe. There are many very well meaning PTs out there and we are not in this to shame or accuse specific people of evil motives, only to expose specific theories and/or interventions in physical therapy. We acknowledge that patients do get improvement with some of these techniques, but strong claims call for strong evidence to back it up.
Individuals will be used as examples from their own videos or published articles, but in every case we will use as much of their own material as possible so they can speak for themselves. Oh, and this is not an educational/research site, so if you have a problem with satire you should just move on.
Postural restoration (in the following to be referred to as PR) started from the observations of Ron Hruska. He noticed common asymmetry patterns, how they occured with overuse injuries, and how that was also related to common postural adaptations that can affect other muscle systems. Here is a brief explanation of “posture” by Ron from his website:
“Posture is a reflection of the “position” of many systems that are regulated, determined and created through limited functional patterns. These patterns reflect our ability and inability to breathe, rotate, and rest, symmetrically with the left and right hemispheres of our axial structure.
“Limited functional patterns” refers to movement that is restricted in directions, planes or normal boundaries of functional range, as a result of improper joint, muscle, and mediastinum rest position. Function is therefore limited because soft tissue and osseous restrictions prevent one from using muscles and joints in their normal range. Adaptation and compensation for these limitations require neuromotor encoding and hyperactivity of muscle that is placed in improper positions that exceed normal physiological length, or in positions that make them a mover or counter-mover in planes and directions that are not observed when one is in a neutral or more symmetrical state of rest. This compensatory activity and hyperactivity usually becomes dysynchronous in the accessory muscles of respiration and at the appendicular flexors and axial extensors, thus limiting functional rotation at the trunk and through the lumbo-pelvic-femoral and cranial-mandibular-cervical complex.”
I’ll just let that speak for itself.
I reached out to several physical therapist via email and Twitter on their thoughts regarding PR. Many responded very similarly with quotes like, “The first class was great, a different way of looking at things.” “I was okay with it at first, but the farther you get in the crazier it gets.” “They lost me for good when they started talking about mobilizing cranial bones and how every pain possible in your body is from your rib and pelvic position.”
So, I started digging around…and it certainly did get crazy. But don’t take my word for it, here are some videos that will explain things for you.
I guess how you breathe can give you plantar fasciitis?
I never knew how crucial tongue and jaw reciprocal movement are in runners!
This apparently is one of the main exercises they use in PR…
And someone sent me this link. I guess they have a vision center as well? Here is a statement from the page link.
“…they have discovered that when they use a very specific and specialized eyeglass prescription along with a patient-specific program of PRI exercises, the brain and nervous system seem to re-wire themselves and this new nervous function can become permanent for long term results. The simplest way to explain how PRI Vision works is to say that we can purposely turn off muscles that are over-active and tight (called too much extension tone), and turn on muscles that are under performing and weak. This is true for muscles from your head all the way down to your feet. This rewiring allows the patient to override their dysfunctional way of moving and doing things.”
It really is miraculous. Consider this video that I found as 100% proof. Really…Just watch it, please.
I find it interesting that the Postural Restoration Institute has a tab called ‘The Science’… which has no scientific references at all…it’s really just an explanation of the terms they use and theory behind PR. I thought I had finally found some actual research when I saw the section of the website called “research topics” but was more than a little disappointed to find out it was only a list of things they recommend researching… Ummm… Yeah…
But then I struck gold! Here’s the area that lists articles from the media, from PRI, and peer reviewed journals. There is an article written by Ron Hruska from 2005 entitled “PRI – An Evidence Based Approach” which lists no specific evidence for PR, but promises to follow up on getting that research going. And then you find this article, which is the only research they have on the site that isn’t a case study or an explanation of the theory behind PR. It involves 13 subjects and is used to show that abdominal and hamstring muscle activation can decrease a positive Ober’s test and also decrease LBP. One would assume that over the last 10 years there would be some kind of research specific to PR. And the one article linked before is flawed in so many ways (no control group, no follow up, etc, etc, etc) that there is no way to make a serious conclusion that PR is actually beneficial.
The above is fun and all, but this page was by far my favorite. It describes how PR is a great conservative approach for treating scoliosis. I hope you don’t mind if I take some quotes from the page.
This is from the top of the page. “Clinical experience of Postural Restoration Certified therapists provides specific clinical data to support the use of PRI techniques as much as if not more so than other approaches to physical therapy.” Holy shit this is impressive! Now we’re getting somewhere. Let’s keep reading…
This little disclaimer is snuck in in the middle of the page…”At this time we have no supportive literature/research articles, pre-post x-rays, or case studies to support PRI intervention with scoliosis patients. We are still in the discovery stage of clinical data collection. Clinical outcomes, however, are very promising and positive especially when parents, patients, and physicians are all supportive of the PRI approach.” Hmmm…but, there’s surely more promises, right?
Yes! “Neutrality and stability of the pelvis can be achieved through Postural Restoration Institute™ non-manual techniques which activate the ipsilateral hamstrings and ischiocondylar adductor and contralateral gluteus maximus for sacral stability and neutral position.” Don’t you worry about citations for those claims, be impressed by the really big words!!!!!
You may want to check out Ron Hruska on Twitter. If so, here’s an interesting tweet I selected…
So, let’s close with some thoughts and advice from Uncle Awesome. There is a great danger in becoming a guru. You can fall into a situation where you are treated damn near royalty…or even divine. You can start to find yourself in that weird gray area between solid ground and fantasy land, and if you don’t have anyone in your life to tell you that you’ve gone over the edge, you’re a gone. The things that are helpful in PR are not exclusive to PR. Relaxation, focus on breathing, strengthening your hips and hamstrings, these are all great things for those dealing with LBP. But once you’ve gone down that rabbit hole, and thrown up the middle finger to science and research, there’s nothing at all to stop you from talking about putting on special glasses to take away your knee pain. And this is especially true if you have no grasp at all on the placebo effect.
Frankly, this is why anecdotal evidence is dangerous. Hell, I can look back over my career and see multiple times where clients got better in spite of me and the interventions I used (cross friction massage for one)! Just because something works for one person does not mean you can extrapolate those results into every single person who has ever lived. I’m sure there are tons and tons of Postural Restoration therapists out there that are very well meaning and very sweet. But if you really feel that every single person who comes through the clinic doors needs to activate their left hamstring while reaching with their right arm to purposely focus on expanding a specific lobe of your lungs with a posterior pelvic tilt with your adductors engaged….you might have just jumped the shark. It’s appropriate to point out that some of the dumbest people I have ever met are also very intelligent. I had a client in Mensa who was easily the biggest fool ever for get rich quick scams. Just because you have a Doctorate or even a PhD doesn’t mean I’m going to simply take your word for it. If the best thing in 25 years that PR can come up with is case studies, they obviously have no intention of backing up their ridiculous claims.
Congratulations PR, you have officially made me feel like apologizing to the chiropractors. I’m not going to, but I feel like it!
As always, thanks for stopping by.