Almost everyone will struggle with back pain at some point in their lives. For some it comes and goes, for others it’s a once in a while thing, and for others it becomes a part of their lives.

What’s even more concerning is that the outcomes for surgery for back pain are not that great. Several studies have shown that long term results for patients who had surgery for their back pain were the same as those who were treated with exercise and cognitive therapy.

Why doesn’t surgery work?

Our spines are complex, we humans are complex! The thinking that the source of the pain is always at the location of the pain is almost always wrong unless you had a direct trauma to that area.

This is because we compensate, and we do it really darn well.

Have you ever had to wear a cast or boot after spraining (or breaking) your ankle or your foot? Maybe you even had to use crutches. Soon, your arms, neck, and hips and probably some other body parts will start to hurt. (Don’t worry, I’ll get back to the back pain soon, stick with me here!)

But there was no direct injury to anything except your ankle! The pain in those other areas occur because you are compensating for not being able to use your foot properly.

The problem is, we all have histories of injuries that make us compensate slightly, and underlying all of that we have an asymmetrical brain and an asymmetrical body that will make us prefer to do things differently on one side than the other.

That’s not really a problem if you’re a wild human foraging for berries or climbing trees all day. But if you’re a modern human, you’re forced into positions (sitting at your desk or your car) and actions (writing, typing, opening doors) that your body will do over and over and over again on the same side.

This creates asymmetries that become ingrained, and now we have to compensate somehow.

So what does this have to do with back pain?

The Postural Restoration Institute, or PRI, clarifies how these asymmetries affect us and can cause problems. Here is a brief synopsis of why and how our asymmetrical nature impacts our lives…

We have a more stable, domed, strong diaphragm on the right accompanied by a flatter, weaker diaphragm on the left. this makes us feel much more comfortable standing over our right leg.

This orients our pelvis slightly to the right.

But nobody walks around with their body pointed to the right! No, we compensate to bring our chest back around to the left, so we can see where we’re going.

So, basically, our pelvis is pointing right, while our ribcage is pointing left. With walking and other alternating activities, we alternate by turning our pelvis to the left and ribcage to the right, but because of the strong anatomical tendencies listed above, we can lose this ability to alternate symmetrically.

Over time, or with repetitive activity, or injuries, we can become “stuck” in this twist. Some degenerative changes can occur, but the research unequivocally shows that disc degeneration or arthritis is usually NOT the cause of back pain (in studies where they scanned hundreds of people, some with back pain and some without, there was no correlation with back pain and arthritis/disc disease or other imaging findings. In fact, some people had severe pain and no findings on imaging, while others had severe degeneration, arthritis, and bulging discs, but no pain)!

The key to getting out of back pain for good is not going under the knife, but rather learning how to bring your pelvis back around to the left, and your trunk back around to the right.

To do so, breathing must become re-organized and re-balanced (remember that the diaphragm is the start of all this asymmetry!) and new movement patterns need to be established.

One very simple thing you can do to start training your body out of compensation is working on getting your left lower ribs down, in, and back. This will promote doming of the left diaphragm and bring your trunk back to a neutral position over your pelvis.

Here’s how to start re-orienting your ribcage to untwist your spine:

References:

Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976). 1983;8(2):131.

Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine (Phila Pa 1976). 2009;34(10):1094-1109. doi:10.1097/BRS.0b013e3181a105fc

Brox JI, Nygaard ØP, Holm I, Keller A, Ingebrigtsen T, Reikerås O. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis. 2010;69(9):1643-1648. doi:10.1136/ard.2009.108902

Rao D, Scuderi G, Scuderi C, Grewal R, Sandhu SJ. The Use of Imaging in Management of Patients with Low Back Pain. J Clin Imaging Sci. 2018;8:30. Published 2018 Aug 24. doi:10.4103/jcis.JCIS_16_18

Wáng YXJ, Wu AM, Ruiz Santiago F, Nogueira-Barbosa MH. Informed appropriate imaging for low back pain management: A narrative review. J Orthop Translat. 2018;15:21-34. Published 2018 Aug 27. doi:10.1016/j.jot.2018.07.009

Lateef H, Patel D. What is the role of imaging in acute low back pain?. Curr Rev Musculoskelet Med. 2009;2(2):69-73. doi:10.1007/s12178-008-9037-0

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.

Tag: asymmetry

Back Pain? How to Address the Root Cause

The Illusion of Symmetry

Let’s Talk Asymmetries.

So what’s the big deal about the diaphragm?

Are you transitioning well from right to left stance?