3 Systems that Help You Balance (and What Happens When They Fail)

We rely primarily on three systems to tell us where we are in space and in relation to gravity. Basically, they keep us from falling over!

Visual System

One of those systems is our vision. Have you ever been parked in your car and slammed on the brakes because the car next to you started to move? Nothing else changed except your visual perception, which made it appear you were moving. As a result, your body reacted. These reactions are constantly happening on a smaller, subconscious level as we negotiate our environment. Don’t believe me? Try balancing on one foot. Now, try that again, but close your eyes. Once we take away the visual input, balancing is much harder.

Human Eye — The visual system is one of the ways that we balance.

Somatosensory System

Another way we balance is with our somatosensory system. This system is the information we get from our body of where we are in space, primarily our feet. All of our joints have specialized nerves in them that tell our brain their position relative to a surface. There is a high density of these nerves in your ankles. To experience the somatosensory system in action, try again to balance on one foot. Notice how much harder your ankle is working, with little micro adjustments, to balance when you have only one foot on the floor instead of two. That’s because you’ve reduced your “somatosensory input” by reducing the amount of contact you have with the ground. Just like our vision, our somatosensory system is constantly sending signals to our brain and making micro adjustments based on where we are relative to a surface. This is happening whether we are standing, sitting, lying down, doing a handstand, walking or running.

Vestibular System

The third system in our body that keeps us from falling over is our vestibular system. This system is usually the hardest to understand because we can’t see it, and we don’t notice that it is working. However, when it is not working, we really feel it.

The vestibular system is a small organ that lives deep to the ear, and you have one on each side. It is often referred to as the “inner ear” for its location, but you cannot get to it from your ear because it is separated by a membrane (the ear drum). It shares a nerve with the part of your body that manages hearing, called the cochlea.

Vestibular organ relative to ear. — The vestibular system or “inner ear,” shown above in blue, is located deep to the membrane of the ear drum.

The vestibular system consists of three semi-circular canals that are filled with fluid. When we move our head, this fluid is displaced. This displacement activates nerves within the vestibular organ and sends a signal to your brain with information about which direction your head is moving and how to adjust your eyes to account for this. This is a crucial function for daily activity. Think about walking. When we are walking, our head is constantly bobbing up and down with each step. However, we do not perceive this because of the vestibular system communicating with your eyes to account for this.

When Systems Fail

These three systems, visual, somatosensory, and vestibular, all have to work together. When they don’t, we can feel dizzy, off balance, or “not quite right.”

The system that is usually affected in feelings of dizziness is the vestibular system. A common cause of dizziness is called benign paroxysmal positional vertigo, or BPPV for short. This is when a small crystal of calcium-carbonate becomes displaced from another region of the vestibular organ and ends up in one of the fluid-filled, semicircular canals. Because the inertia of the crystal is greater than that of the fluid, the brain and eyes receive a signal that you head is still moving when actually it has stopped. Therefore, this type of dizziness usually occurs with head movements and creates a spinning sensation. It can be very uncomfortable, and is treated by a maneuver that positions the crystal back to its original location. Crystals can become dislodged during a head trauma. Also, as we age the crystals do not adhere as strongly to their original location and can come loose all on their own.

The vestibular system can also be damaged by a virus. Usually, someone who has this issue had a stomach virus or head cold up to two weeks before they started feeling dizzy. This person also gets dizzy with head movements due to the virus affecting the nerve that sends information from the semicircular canals to the brain, body and eyes.

Inflamed vestibular nerve — Our sense of balance can be affected by an infection that makes its way to the nerve transmitting signals from the vestibular organ.

When our vestibular system is damaged or not functioning as well, we rely more heavily on other systems of balance, usually our vision. We usually don’t rely as much on our somatosensory system because in our day to day we are far more used to using our eyes to stabilize (computer work, driving, watching TV) than we are to using our somatosensory system (walking on uneven surfaces, balancing, crawling). This can make us feel dizzy when we are in an environment with lots of visual stimulus, or make us feel off balance or dizzy when we are in the dark or low light. After a while, we might notice that our neck becomes stiff, because we also avoid head movements that may make us feel dizzy.

Our bodies and brains are extremely good at compensating, but we can only compensate for so long. For individuals who have dizziness or imbalance and try to “just deal with it,” their problems often become worse as the compensations only grow stronger. This is because your body will always take the path of least resistance, which means it will always preferentially use the systems that are already strong (usually vision) and therefore the ones that are weak (vestibular and somatosensory) become weaker and weaker. This creates an imbalance that affects us negatively in many ways, because there are many moments in life we need all three systems to be working well and harmoniously.

So what to do if you suspect your balance systems are, well, out of balance? The best thing to do is to strengthen those that are weak. You can do this by performing balance activities with eyes closed, or incorporating head motion into your activities. This way you will stimulate the somatosensory and vestibular systems, and with eyes closed the visual system will not be able to take over.

January 18, 2020February 18, 2020

Find Your Wings: 3 Things You Should Know About Your Shoulder Blades

We all have them, the big broad bones that fold onto the back of your ribcage like wings. But what do we really know about them?

To understand the function of the shoulderblade, or “scapula,” we must first understand their form.

1. The only bone to bone attachment of the scapula to your trunk is a tiny joint where your collarbone meets the top tip of the scapula.

This joint, called the acromioclavicular joint, or AC joint, is about as secure as if you put the tips of your two index fingers together head on, i.e. it’s pretty flimsy.

picture of two hands with the tip of the index finger touching. This represents the AC joint. — *The joint between your shoulderblade and the rest of your body* is about as secure as the joining of two fingertips.

The crazy thing is that the arm bone attaches to the scapula bone via a shallow concavity, and the scapula is attached to the rest of your body via the above mentioned AC joint. Literally the only bony attachment of your arm to your torso is via a tiny, flimsy joint.

Small attachment of scapula to torso via the acromioclavicular joint, aka the AC joint. — The acromio-clavicular joint, or AC joint, is the only connection between the scapula and the rest of your torso.

So, you’re probably wondering at this point, “how is my arm not falling off?” It is pretty amazing that our arms not only stay attached, but that we are able to climb, crawl, draw, reach, swim, etc with such precision and stability.

2. It is mostly muscle that holds our arm onto the rest of our body.

This is an amazing design because it allows for a huge degree of mobility in the shoulder, which is necessary to do all the precise tasks and vast ranges of motion required of our arms.

However, this can also create a lot of problems. Muscles change their function based on their position, and repetitive, habitual movement patterns can place muscles in suboptimal positions. If we always sit at the same desk, with our phone on the same side, or we always sit the same way in the car, or always throw a ball with one hand, we are slowly but surely ingraining one-sided patterns into our bodies.

When this occurs in the shoulder and shoulderblade regions it is especially impactful due to the heavy reliance of the shoulder on muscles for stability. This is why shoulder injuries often have little to do with the shoulder, unless it was due to a direct trauma. Usually it is a muscle imbalance or aberrant positioning around the scapula that is the issue, even if the pain is felt in the shoulder.

3. Our shoulderblades are concave in shape

Even though at first glance it seems that are shoulderblades are flat, they actually have a concave shape. This allows for the shoulderblade to sit on the ribcage, which is egg-shaped.

Shoulder blade (Scapula) shown from the side. It has a concave shape. — Side view of a shoulderblade showing the concave surface that touches the ribcage.

However, many of us tend to change the shape of our ribcage by changing the way we breathe. For example, a common pathological breathing pattern is pushing the front lower ribs up in order to get air in without completely exhaling. This is a common breathing pattern when we are stressed- it is a shallow, more rapid breath. If we are a little stressed most of the time, our breathing will reflect that, and over time the shape of our ribcage will reflect that as well.

What this “stress breathing” pattern does is create a flattened ribcage in the back, so now we have a concave shoulderblade trying to sit on a flat surface. At this point the muscle activity cannot be restored because it is the structure underneath that is the issue, and must be corrected before the shoulder can start to move better and feel better.

The shoulderblade is often overlooked when we think about how we move our bodies, but its position and function is vital to our arms being able to move well and without pain. Keeping the muscles around your shoulderblade strong and in an optimal position, as well as keeping your ribcage well positioned with proper breathing, will preserve the life of your shoulders and make for a much happier and painfree shoulder complex.

January 14, 2020February 18, 2020

How to find Stability in your Yoga Practice

With the exponential growth of yoga in the last few years, class sizes are getting bigger, and the content more imaginative. It is wonderful that more people are exposed to yoga. As a physical therapist, what concerns me is the lack of emphasis on internal stabilization. This stability comes from deep muscle activation, in sanskrit called bandha, which translates to “Lock.”

In our fast-paced lifestyle, we are often tempted to put ourselves in a position of compromise to “just get things done.” We skip the part where we find our sense of center, and we forget to return to it repeatedly. This is what the practice of bandha teaches us. Developing the bandhas takes effort to build strength, vigilance to maintain, and patience to master. However, once the bandhas are in place, all the other aspects of yoga practice become more accessible, fluid, and enjoyable.

Bandhas stabilize the body during dynamic movement. Some yoga postures can even be damaging if done repeatedly without this awareness. Sure, a teacher might now and then mention a bandha, or advise students to “engage the pelvic floor.” . The problem is that many people have never been taught how to access the bandhas in the first place.

yoga on a mountain top representing internal and external stability — Yoga and the bandhas can apply to every day life.

What are bandhas, and how do we access them?

In yoga there are essentially three bandhas in the body. The main two we will discuss today are “mula bandha” and “uddhiyana bandha,” which represent the pelvic floor muscles and the transversus abdominus muscle, respectively. These are the deep stabilizers of the trunk and pelvis. The third bandha is “jhalandara bandha,” which involves the core muscles of the neck and head known as the deep neck flexors (longus colli and longus capitus muscles).

Mula Bandha (Pelvic Lock)

Let’s start with mula bandha, the root lock, or the pelvic floor. In physical therapy practice we often teach patients to engage their pelvic floor if they have hip, back, and leg pain. I even now teach pelvic floor exercises to help patients who have neck pain, because the pelvic floor is the “foundation of the house.” If the head and neck are the roof of the house, you can imagine how a poor foundation would result in an unstable roof.

In my experience working with patients, these muscles are inherently difficult to engage for several reasons. The first is that they are “postural muscles.” Unlike big mover muscles, like the thigh muscles that bend the knee, the postural muscles are under subconscious control. This makes it difficult to fire them at will, and they are harder to feel. The thing that makes pelvic floor muscles really hard to access is the fact that we can’t see them, and many people have never even heard of them.

How to access Mula bandha

As mentioned above the pelvic floor is hard to access, but visualization can be helpful.

Sit on a firm chair with knees and hips at 90 degrees and feet flat on the floor.
Sitting up straight, hinge forward and back from the pelvis until to feel ventered on your sit bones (the boney protrusions at the base of the pelvis).
From here, draw the sit bones closer together, without tightening your gluteal muscles.
Keep this as you visualize the sit bones pressing down into the chair, as the space between them moves up (this is the doming up/activation of the pelvic floor muscles that make mula banda).
If you can achieve this lifting sensation, you can try maintaining that while visualizing your coccyx (the tailbone) and the pubic symphysis (the very front of your pelvis) also moving towards each other.
These four points (the sits bones, coccyx, and pubic symphysis) all are moving towards a central point.
Even if you feel nothing initially, with continued visualization you will begin to feel something. It is a process.

Uddhiyana Bandha (Navel Lock)

Also known as “flying up” bandha, this is the place between your navel and your pubic bone that wraps around your waist. It creates lightness and lift, and stabilizes the trunk and pelvis during movement and during static standing and sitting. A long, flat sheath of muscle, this bandha is made up primarily by the transversus abdominus and the internal oblique muscles.

The transversus abdominus muscle which activates navel lock, or uddhiyana bandha — The transversus abdominus muscles that make up uddhiyana bhanda.

How to access Uddhiyana Bandha

One accessible way to feel uddhiyana bandha is by activating the leg muscles strongly.

Stand with your feet hip width apart, feet parallel.
Draw up through the inner arches of the feet, while rooting the base of the big toe, base of the pinky toe, and straight down through the heel. You may feel something light up in your core with just this! If not, no worries, keep going.
Imagine you are drawing all the musculature of your legs up towards your pelvis.
Maintain that as you tighten the front and back of the thighs simultaneously.
At this point you should feel the area below your navel turning on. That is uddhiyana bandha.
Now see if you can relax your legs somewhat while keeping the activation in your abdomen.

Jalandhara bandha (Throat Lock)

While the full expression of Jalandhara Bandha is more applicable during breathwork, a sense of this lock can help with asana practice as well.

Due to our lifestyle that now frequently involves sitting, the head tends to come forward with the chin protruding. Then, when it comes time to practice yoga on the mat, we carry this poor posture with us.

Jalandhara bhanda can mitigate this effect by teaching us to draw the head back over our spine. In the full expression of the bhanda, the chin is nestled in the nook of the breast bone between the collar bones, called the sternal notch. This can be a good release of the fascia along the back of the neck, but is impractical for asana practice and may cause strain for some individuals.

A lighter version of Jalandhara bhanda can help us find a neutral and stable position of the head and neck by recruiting the muscles that make the “core of the throat.” These deep muscles return the head to a neutral position.

How to access Jalandhara bandha (throat lock)

Sit in a firm chair, feeling your sit bones.
Exhale completely through your mouth as you let your neck and shoulders relax and your front lower ribs move down and in (for more info about the importance of the ribs here, see my other post “the posture myth”)
Now, draw your head straight back so that it sits atop the rest of your spine.
Maintain a relaxed posture of your neck and shoulders as you draw slightly nod your head down as if you are holding a small orange between your chin and the space between your collarbones.
Imagine the base of your skull floating up as your chin drops slightly, lengthening the back of your neck.
Check to see that your shoulders are still relaxed. If not, take another exhale and let them drop.
Stay here a few breaths, inhaling to lengthen through the back of the neck, exhaling to settle the shoulders and the front lower ribs.

Yoga and Injury

As a physical therapist, the most common yoga injuries I see are in people who are naturally flexible (usually young to middle-aged women, which happens to be the largest demographic of yoga practitioners). These individuals can put themselves in many challenging postures but lack the deep stabilization of the bandhas. I also see stronger men and women who are able to muscle through arm balances but end up with neck and shoulder pain because really it is the deep connections of the bandhas that create a sense of levity in arm balances, not the arms. Practicing poses with correct activation of the deep stabilizing muscles may mean that you have to approach the pose in a new way, and you may not be able to make the pose look as good initially. This is where the yoga really happens- when we shift our focus from what the pose looks like to what it feels like, when we move from place of integrity and patience.

It can take time to develop a keen awareness of the bandhas and to incorporate them into practice. However, by learning to engage the bandhas, yoga injuries can be prevented and healed by practicing with increased awareness, intention, and patience.

January 6, 2020February 18, 2020

Am I still dealing with My Concussion?

When we think of a concussion, we often think about football players or someone who has taken a blow to the head. While this is where a lot of concussions happen, many more happen in ways that are less talked about. Whiplash, such as from a car accident, can cause a concussion as the brain strikes forcefully against the skull and shears neurons that descend from the brain. In the same way, a fall can cause a concussion – even without a blow to the head, especially in older adults.

Who Gets Concussions?

Concussions can occur in older adults who slip or fall (even without hitting their head!), children, athletes at all competitive levels, military personnel who sustain blast injuries, adults who slip on the ice getting into their car…etc. Basically, anyone can get a concussion.

What is a Concussion?

A concussion is a trauma to the brain significant enough to cause a brief change in mental status or consciousness. Recovery for a concussion has a natural healing time of 4-6 weeks. That means that unless you have signs that you will need rehab immediately, often the best course of action to take during that time is resting appropriately under observation of medical provider.

That said, in my experience there is a lot of confusion about what appropriate rest means, and furthermore what is appropriate is unique to each individual. Too much rest is not helpful, and too little is certainly not helpful, and either of those could be harmful or delay recovery. So please, if you or someone you know has had a concussion (or you even suspect they had one) get clarity on what “rest” means from a provider who is well versed in concussion rehab.

Symptoms of a concussion can be vague and are different for each person. Many people never end up seeking care or are misdiagnosed. Catching a concussion early is very important because the research supports that early intervention results in much better outcomes.

Early Symptoms of Concussion

Headache
Neck Pain
Mood changes
Fatigue
Sleepiness
Nausea
Dizziness
Difficulty Sleeping
Sensitivity to light/sound
Double/blurred vision
Confusion
Balance deficits
Focus/memory deficits

Post-Concussion Syndrome

Many patients, especially those who were not diagnosed or did not receive rehab or proper guidance early on, end up with long lasting symptoms that they just accept as “part of their life now.”

Once it has been 3 months since the original injury, these patients technically no longer have a concussion, but rather post-concussion syndrome, which indicates chronic symptoms. However, patients often don’t realize that these symptoms are still treatable and are not something that they have to live with!

So why do symptoms persist for so long with post-concussion syndrome? The body and brain find ways for you to keep doing what you have to, by compensating for deficits rather than addressing root causes. For example, when you have a deficit in the part of your nervous system that tells your brain where your body is in space, you compensate by relying on vision for balance. This works okay for a while, but dizziness occurs when your vision is over stimulated, such as when you are trying to look around while hiking, or are in a visually stimulating space such as the grocery store, or when you can’t access your vision well, like in a dark movie theater.

Symptoms of post-concussion syndrome

Dizziness
persistent headaches and/or neck pain
reduced tolerance to lights/sounds
feeling unsteady, especially when walking or in busy environments
fatigue
a sense of fogginess or feeling “not quite right.”

What can be done to help?

When a person experiences dizziness or balance deficits, the affected systems need to be trained with specific exercises at optimal dosages. Over time, these treatment strategies reduce your symptoms by teaching your body to move away from compensation and strengthen the parts of your system that have become weakened.

As I mentioned before with rest, knowing exactly how much to do and when is key for achieving recovery. Doing too much can overwhelm your system, whereas not doing enough will not result in any gains. That’s why working with someone trained in concussion rehab is essential for you to continue to improve without exacerbating your symptoms.

Longer-term Symptoms of Untreated Concussion:

Loss of libido
Low blood pressure
Loss of mensturation
Fatigue
Muscle weakness
Growth problems (children)
Weight gain
Early dementia
Chronic headaches/dizziness

Long term symptoms of concussion can affect multiple systems of the body.

What to do if you experience a concussion:

Decrease your screen time.
- Try to spend less time looking at a computer screen, phone, or i-pad.
Allow yourself rest.
- After a concussion, most people feel the need to sleep more than usual. This allows the brain to heal. Give yourself permission to spend extra time sleeping.
Continue to engage in light aerobic exercise.
- While vigorous physical exertion may worsen symptoms and delay healing, light aerobic activity can help you heal faster. If you are not sure how much to exert yourself safely, a physical therapist can perform an exertion test to determine how you respond and give you guidelines for how to exercise on your own.
Listen to your symptoms.
- Stimulating environments and even changes in head position can provoke symptoms. If you notice triggers like these, allow yourself to experience mild symptoms but avoid situations that cause symptoms to become severe.

Important Note: Depression and anxiety are one of the most common symptoms following concussion. In 90% of cases these symptoms resolve with time. However, in some cases these symptoms can be more severe or persistent, especially if there is a history of depression or anxiety, or presence of stressful life events. Many patients benefit from more in depth care in this arena, such as meeting with a psychotherapist in addition to physical therapy to achieve full recovery.

Dr Derya Anderson has extensive experience working with patients who have had a concussion. She also has attended continuing education courses (below) that are specific to concussion management:

May 2019 Stress, Movement and Pain. Speaker: Seth Oberst, PT, DPT

July 2018. Concussion: Vestibular System Abnormalities and Ocular Motor Examination. Taught by Susan L. Whitney, DPT, PhD, NCS, ATC, FAPTA

March 2018. Concussion Basics. Assessment, Screening and Risk Factors. Taught by: Anne Mucha, PT, DPT, MS, NCS and Susan Whitney, DPT, PhD, NCS, ATC, FAPTA

March 2018. Clinical Subtypes Following Concussion: A conceptual Framework for Evaluating and Managing Concussion. Taught by: Anne Mucha, PT, DPT, MS, NCS and Susan Whitney, DPT, PhD, NCS, ATC, FAPTA

October 2017 Vestibular Dysfunction- An algorithmic based Evaluation and Treatment. Speaker: Barry Morgan, PT

March 2017 Innovative Approach to the Management of the Cervical Spine: Maximizing Outcomes in Fewer Visits. Speakers: Jeff Ryg, PT, DPT, OCS, FAAOMPT. Kristen Carpenter, PT, DPT, OCS, FAAOMPT

November 2015 Orthopedic and Neurologic Perspectives on Concussion/Mild Traumatic Brain Injury Management. Speakers: Wendy Kriekels, PT, DPT, NCS, David A. James, PT, DPT, OCS, SCS, CSCS, Michael R. Greher, Ph.D., ABPP-CN, Katherine S. Dahab, MD, CAQSM, FAAP

Nov 2015 APTA SIG Event: The Role of Physical Therapy in Concussion Care. Speaker: Ann McNamara, PT, MPT, CCCE

December 18, 2019June 24, 2021

The Illusion of Symmetry

From the outside we look symmetrical. Left to right, it seems that if you drew a line down our center we would get two equal parts. Most anatomical drawings present the human body in this way.

When we dig a little deeper, it turns out that right to left we are quite different, and these differences can have a profound effect on our physical functioning.

Often I have patients ask questions like, “why is it that only my right knee hurts with running?”

Good question! Some may say that this is due to handedness, with most of us being right handed. But have we ever stopped to ask why it is that most of us end up being naturally right handed? I don’t intend to get into a debate about handedness, but it certainly hints that there is something else at play, some asymmetry inherently present in all of us. These asymmetries are normal and natural. However, these asymmetries can become problematic when they become unbalanced.

This can occur due to external or internal circumstances. For example, your life requires that you do repetitive tasks to one side only, like reaching for the phone on the right, or getting in and out of the driver’s side of your car. It may also be something intrinsic to you, such as an injury. If you had an injury to your left leg, you felt more stable on your right leg as you were healing. That is helpful while you heal, but that patterning of preferring the right leg to stand on can remain long after the tissues have healed.

The Postural Restoration Institute has a deep understanding of these asymmetries and how they affect us. This institute is unique in that it addresses these complexities of being a human when creating a treatment plan, which I have not seen in literally any other course or training for physical therapists, even when I was in my doctorate program this was glossed over at best.

Let’s Talk Asymmetries.

The primary source of these asymmetries is the center of our body, the trunk. It is the generator of motion in our limbs and it is our center of stability. At the center of our trunk (the “core of the core,” if you will) lies the diaphragm, which is dramatically impacted by the asymmetries of our organ and lung placement.

The diaphragm on the right tends to be more domed due to:

lower attachments of the diaphragm onto the right side of the spine compared to the left.
The central tendon (which makes the dome of the diaphragm) is thicker and stronger on the right than the left.
The right diaphragm has the support of the liver underneath.
The presence of three lung lobes on the right and only two on the left to make space for the heart.

Radiograph showing the right diaphragm (left side of picture) being higher than the left. This is normal human patterning.

All these things cause the right rib cage to be in an “exhale” position with the ribs dropping down and into the body, and the ribs on the left to be in an “inhale,” an elevated and expanded position. Think of the left lung as a big balloon pushing on the smaller balloon on the right. This causes an orientation of our ribcage to the left. The attachments of the diaphragm on the spine cause the spine to turn right.

The Postural Restoration Institute has recognized this natural asymmetry and incorporates this anatomical variance into their training of physical therapists and therefore the treatment of our patients. When I first heard that everyone is biased one way, it was news to me. When I was in my doctoral physical therapy program, we learned all the asymmetries of the vital organs, however the influence of this asymmetry was not applied to physical function. Furthermore, the asymmetrical structure and pull of the diaphragm was hardly mentioned, if at all. I find this surprising now as the diaphragm is a muscle that we use all day, every day, and it has profound impacts on how we move and interact with our world.

So what’s the big deal about the diaphragm?

The diaphragm is huge! It attaches to our lower back spine and interfaces with our abdominals, low back muscles, and hip flexors. After I took my first postural restoration course, I was pleasantly surprised at the emphasis on diaphragmatic function and it’s role as a driver of human movement. I was also surprised at how “belly breathing,” which I taught and practiced myself, was actually detrimental to harnessing the power of the diaphragm. The inherent asymmetries within our diaphragm drive the initiation of human movement, specifically walking. Essentially, the stability of the right diaphragm supports right stance phase of gait (standing on your right leg and left leg swinging).

walking still shot in Right stance phase with left swing phase

The problem occurs when we go to stand on our left leg, but we are still in right stance with our supporting muscles. The left diaphragm is not able to support our body in this position, and our right leg does not adequately recruit muscles to swing the right leg. This occurs not just in walking but also during day to day tasks. This can create all kinds of issues, knee pain on one side being just one of them. Fortunately, this asymmetry can be addressed with specific exercise that is asymmetrical, and therefore corrective. These exercises incorporate the breath to achieve diaphragm function.

Once again, I want to reiterate that this asymmetry is not a bad thing inherently. It is in fact a wonderful thing as it initiates the walking cycle and allows us to begin rotating through our trunk and pelvis. Asymmetry becomes a problem when we get stuck on one side, and are not able to get over to the other side. Relearning how to transition from right to left, and then back from left to right, is how we get balanced again.

Are you transitioning well from right to left stance?

You may have difficulty transitioning from side to side if you:

Tend to always have tightness in one hip more than the other
Always cross one leg over the other (usually the left one over the right)
One leg feels longer than the other
You notice different wear patterns on your shoes or bike saddle

Try this simple exercise to test your asymmetry:

Stand with toes pointed straight forward (feet not turned in or out). Keep this foot alignment as you transition to standing on one leg. You can touch a counter in front for support. Now, turn your pelvis so that the zipper of your pants comes over your right big toe. Try the same thing standing on the left leg, toes pointed forward, knee slightly bent. This time, try to turn the zipper over your left big toe. Notice if you can do this on one side, but not the other.

If you find one side to be challenging, but not the other, that indicates you may have trouble shifting to one side. Because of our natural human pattern, it is usually harder to do this standing on the left leg. That doesn’t mean you can’t stand on that leg at all, but it means that when you are standing you aren’t using the correct chains of muscles, which results in pain and dysfunction. To address this issue, come see me or a PRI trained therapist near you to get properly screened and the tools to find better ease and balance in your body.

November 6, 2019August 29, 2021

The Posture Myth: Why Straighter is not Better

Most of us remember being told to “sit up straight!” or “shoulders back, chin up!” as a child or maybe more so as a teen. While this advice was given with the best intentions, it may not have been that helpful. Don’t get me wrong, I’m not advocating the slumped computer posture with shoulders rounded and head poking forward.

This is certainly not a biomechanically sound posture and can lead to all sorts of dysfunction and pain. In an effort to avoid this unsightly slump, we may find ourselves in a position I call “reverse slumping.” This is the tendency to pull the front lower ribs up and push the chest forward. While this may look more upright, it is an overcorrection, and can be more problematic than helpful.

The Problem

So what’s wrong with a lifted chest and elevated front lower ribs? The problems that arise are largely due to how we breathe, and the important relationship between the ribcage and the pelvis. The Postural Restoration Institute has defined the relationship between the breath and function. Below is my meager take on their extensive understanding of the topic. For more information check out https://www.posturalrestoration.com/.

1. Poor oxygenation. If our front lower ribs are “flared” up and out, the mid-upper back is essentially closed off and becomes flat. This causes many problems, one of which is poor oxygenation. The human body is designed to breathe into the back mid and lower ribs, not just the front. These back middle and lower regions of the lungs have the largest area of lung tissue, and the highest blood flow to lung tissue ratio. This means that this area is very important for getting oxygen from your lungs to the rest of your body. When this is closed off (by pushing front ribs up) we are forced to breathe shallowly into our front upper chest, which may recruit neck muscles to help inhale and result in increased neck tension (among other issues). Further, it is harder to get air out because the chest is in a hyper-inflated state. This means less new, oxygen-full air in. Theoretically, if you improve the expansion of your mid back, you will use oxygen more efficiently and fatigue less quickly with sport and daily living.

2. Altered neck and shoulder mechanics. The spine is not meant to be straight, rather it has natural curves that allow a springy quality for shock absorption. When the front ribs are pushed up, the upper back spine becomes flat. This destabilizes the shoulders, as the shoulderblades are designed to function on an egg-shaped surface, not a flat one. As a result, the muscles that manage the shoulderblade cannot function optimally, thereby changing the mechanics of the shoulder in an adverse way. Many of the muscles that attach to the shoulderblades also attach to the neck spine and can create increased tension in the neck area if they are not functioning well.

The muscles that attach to your shoulderblades, back, and neck can become strained and painful with poor posture.

A flat upper back also burdens the point where the upper back spine meets the neck spine. The neck spine is naturally curved and is designed to follow the curve of the upper back. However, if the upper back is now flat, the spring-like shock absorbing factor is lost. Furthermore, the juncture from upper back spine to neck spine becomes vulnerable due to a sharp corner instead of a nice smooth curve between the vertebrae. This can create pain and sensations of tension in this area.

3. Increased stress levels. When we are stressed, that really means our body is entering a “fight or flight” state, which means that there is some imminent threat, and we need to either fight or get away. Blood is shunted away from the core and immune function and digestion are halted as the body prepares to fight or flee. This threat could be anything from being chased by a mountain lion to a steady drip of small daily stressors, like traffic, aches and pains, worrying about money, etc. Our body simply does not distinguish what the cause of the stress is, the same pathways and neurotransmitters are stimulated in the case of a lion attack or spilled coffee. The “fight or flight state” has its purpose, however it is not healthy to remain in this state for prolonged periods of time.

The part of our nervous system that promotes our “rest and digest” state is governed by the vagus nerve which passes from the brain to the abdomen through the ribcage. This state allows the body to be calm and relaxed, allowing for sleep, healing, and digestion. When we are in this state, our breathing is full and deep, with the diaphragm moving through its full range of motion.(1) This is the state that we should be in most of the time.

So what does this have to do with posture? Well, if we push the front ribs up and close off the back of the ribcage, the sympathetic ganglia (the nerves that promote a “fight or flight” state and live along the upper back spine) become overly stimulated due to compression. Furthermore, with the front ribs elevated, the body is in a constant state of shallow inhales and exhales, which is correlated with higher stress levels and promotes release of stress hormones in the body.(2) What’s really amazing about our bodies is that this system works both ways. That is, just as the state of our nervous system causes our breathing patterns to change, we can similarly alter our nervous system by modifying the way we breathe.

4. Poor recruitment of deep abdominals, especially upon inhale. Even if you have six pack abs, that doesn’t necessarily mean you are using the abdominals in the way they are meant to be used. Deep to the well known “six pack” of the abdominals are deeper muscles that create a cylinder around the center of the body. These are breathing muscles. They attach to the lower rim of the ribcage and the upper rim of the pelvis. They create stability and order within the body as well as reduce pressure on the lower back spine and associated nerves. They allow us to be both stable and mobile when they function correctly.

When the front ribs are excessively elevated, the front of the pelvis is often tipped forward as a counterbalance. This places the deep abdominal muscles in the front of your body in a state of excessive length. Our muscles do not function very well (or hardly at all) from their most lengthened state. It’s like trying to pick up a heavy bag of groceries with your arm totally straight instead of slightly bent. It just doesn’t work as well.

A deep stabilizing muscle, called the transversus abdominus, helps us maintain neutral posture.

So then what is good posture?

Essentially, your rib cage should be egg shaped, and sit atop your level pelvis. The spine should be lengthened while maintaining its natural curves. In sitting, you can achieve this by:

Sit in a firm chair with your feet flat, knees and hips at 90 degrees.
Feel your sit bones (the boney protrusions at the base of your pelvis). You may need to lean forward and back a few times to find where you feel them most. When you are most aware of your sit bones pressing into the seat, this indicates that your pelvis is level. It may feel like your pelvis is slightly “rolled under.”
With a long, relaxed exhale breath through your mouth, allow your front lower ribs to drop down slightly. Pause a few seconds at the bottom of the exhale. There should be a sense of your front lower ribs coming down to the front top rim of your pelvis.
Maintain this position as you imagine your lower back ribs expanding with each inhale, and your lower front ribs moving down and back towards your spine with each exhale. Hint: pausing after your exhales for 3 seconds will make it easier to feel back ribs expanding.
Below is a video on finding a neutral sitting posture.

And there you are! If you are used to pushing your chest up, it probably feels like you are slouching when you come into a correct posture. To assure yourself that you are still sitting straight, you can use a mirror to see that you are indeed not slouching. If you can see yourself from the side in the mirror you may also notice that now you have a little more expansion in your lower back ribs. Good job!

References:

1. Russo MA, Santarelli DM, O’Rourke D. The physiological effects of slow breathing in the healthy human. Breathe (Sheff). 2017;13(4):298-309.
2. Hirotsu C, Tufik S, Andersen ML. Interactions between sleep, stress, and metabolism: From physiological to pathological conditions. Sleep Sci. 2015;8(3):143-52.
3. Tenney, R., KL Boyle, A DeBord. Influence of Hamstring and Abdominal Muscle Activation on a Positive Ober’s Test in People with Lumbopelvic Pain H. Posturalrestoration.com. Accessed January 26, 2019.