Evidence Based







5 Postural Restoration Benefits: Lower Pain While Improving Performance


Postural restoration - Dr. Axe

As children, we tend to use both sides of our bodies much more easily compared to when we’re adults. As we age, we gradually start to favor one side of the body, forming muscular patterns as we repeatedly strengthen our dominant side. The result is that over time — when we do this over, and over, and over again — our learned muscle patterns wind up affecting our posture and how our body functions, especially how we breath and move.

The goal of postural restoration (or PR), according to Dr. Skip George, D.C, a Certified Chiropractic Sports Practitioner (CCSP), Certified Strength and Conditioning Specialist (CSCS) and Postural Restoration Certified (PRC) Practitioner, is to “improve bodily functions and perform at a higher level, both in our younger years and in our eighties or beyond. Postural restoration is really a treatment approach for all ages and abilities.”

In 2014, Dr. George was the first chiropractic doctor to become Postural Restoration Certified (PRC) with the Postural Restoration Institute® (PRI). He was also invited to join the PRI teaching faculty in 2015 and teaches a course for the institute called “Postural Respiration.”

In his opinion, the trick to postural restoration treatments is figuring out which dominant or overused muscles in the body need to be” turned off” or “inhibited”, and which muscles that are underused need to be “turned on” or “facilitated.” Addressing dysfunctional muscle patterns that are driven by the nervous system can allow someone to ultimately live a more balanced life.

Michael Cantrell, who holds a Masters in Physical Therapy and is also certified through PRI and a senior faculty member for PRI, teaches several primary and advanced courses for the faculty and mentors other faculty members. He explains that postural rehabilitation is really about gaining self-awareness regarding your own body, learning to become your own “realignment specialist.”

Cantrell has been researching physical medicine and postural therapy for over 30 years, allowing him to successfully treat hundreds of patients in his clinical practice. He explains that over time with postural restoration, patients can learn how to walk the best way they can, breath the best way they can, and exercise in a way that helps decrease their compensations, pain and limitations, instead of contributing to them.

What Is Postural Restoration?

According to the Postural Restoration Institute® website, the PRI treatment approach is a type of physical therapy that is established to “explore and explain the science of postural adaptations in the body, asymmetrical patterns, and the influence of polyarticular chains of muscles.” Postural restoration considers the influence of the skeleton, muscles and dental occlusion on posture and functionality.

What is PRI’s mission? Practitioners who practice PR aim to use innovative treatments to help address and correct the primary contributions of “postural kinematic movement dysfunction.” That might sound like a mouthful, but it’s a pretty straightforward concept: specific postural exercises and techniques, including those that address breathing and the alignment of the body, can help reposition the pelvis, rib cage and other parts of the body. These exercises help “turn off” muscles that are on too much of the time, and also activate other muscles that have been turned off for too long.

What types of symptoms can PR help treat? Any that are caused in part by compressed nerves, abnormal torque and muscle tension— including those typically treated with a combination of medications, physical therapy, chiropractic manipulation or even surgeries.

What makes postural restoration unique? Is it similar to other practices, such as chiropractic adjustments or Egoscue, another postural therapy? 

While there are some similarities between these different approaches, most treatments don’t take into account adaptations to human asymmetry as much as postural restoration does. Humans will compensate for their asymmetric form.  Postural restoration is an “evidence-based” approach to neurology, respiration and biomechanics that really is a 21st Century approach to balancing all systems of the human body .

Compensations contribute to pain and poor performance, and they interfere with our ability to function properly. The “big deal” of postural restoration therefore, as explained by Dr. George, has to do with the exploration of human asymmetrical patterning and compensatory strategies that lie within us all. According to Dr. George, everyone has spinal curves that like muscular patterns, can be too dominate in one direction or even lost in another direction. But with help and practice, we can help normalize the body’s curves in order to improve functionality.

Postural restoration guide - Dr. Axe

History of the Postural Restoration Institute:

Ron Hruska, MPA, PT, is the man behind PRI that has spent the last 25 years researching the science and fine-tuning the treatment approach.

Ron first completed a degree in Physical Therapy in 1980 and began working as a PT at the Omaha Veterans Administration Medical Center. After becoming the Assistant Chief and Clinical Educator at the center, along with earning a Masters of Public Administration through the University of Nebraska, Ron went on to accept a position as Director of Physical Therapy and Rehabilitation at St. Elizabeth Community Health Center in Lincoln, Nebraska. His experience led him to the conclusion that asymmetrical patterns influenced posture and movement, and that addressing patients’ asymmetries was one key to helping them overcome a range of limitations.

Ron opened a private practice and physical therapy clinic in Lincoln, Nebraska in 1999 and then established the Postural Restoration Institute® in 2000. A year later he also co-founded the PRI vision center. Today, he is the Executive Director of the Postural Restoration Institute® and continues to teach nearly 20 courses each year both in the U.S and internationally. Additionally, Ron is co-inventor of the Protonics Neuromuscular Training System and invented and patented the Prism and Priori PRI Aquatic systems.

Who Is Postural Restoration For?

There are now more than 150 postural restoration practitioners in practice today. Physical therapists, physical therapy assistant, athletic trainers, occupational therapists, sports medicine doctors, chiropractors and other physicians may all offer postural therapy to their clients and patients. Postural restoration treatments are suitable for a wide spectrum of patients — ranging all the way from young athletes to older adults. Postural restoration is used to treat many different ailments and symptoms, with some of the most common being:

  • Tension in the head and neck
  • Shoulder, knee, hip and back pains
  • Migraines or headaches
  • Chronic fatigue
  • Trouble breathing and other respiratory issues
  • Neurological symptoms including brain fog, confusion and lightheadedness
  • Scoliosis
  • Poor athletic performance
  • TMJ
  • and others

Correcting the position and function of the pelvis, diaphragm and ribcage are key goals of PR. The body functions through asymmetry due to how organs of the bodily systems are positioned (heart, lung, liver, etc.), favoring one side over the other. As the PRI website explains it, “The neurological, respiratory, circulatory, muscular and vision systems are not the same on the left side of the body as they are on the right, and vice versa. They have different responsibilities, function, position and demands on them.”

Practitioners who are certified in postural restoration treatment first begin by assessing a patient’s position and posture. This helps to determine how their posture is affecting the individual’s breathing, everyday movements, athletic performance and quality of life. Every postural restoration treatment plan is unique, customized and tailored to fit the individual’s specific needs.

Poor Posture Causes Pain

What causes us to develop dysfunctional muscular compensations? Some of the most common causes for poor posture include:

  • Too much sitting
  • Inactivity or a sedentary lifestyle
  • Exercising in one direction only (for example, performing bicep curls which only move in one plane of motion, using a spin bike or doing exercises on other types of machines)
  • Repetitive movements
  • Too much hyperextending when exercising, especially in the back
  • Having an anterior pelvic tilt
  • Right side/right side dominance
  • Forward head posture, which stresses the shoulders, neck and upper back

Poor posture results in a number of symptoms due to how it forces the body to compensate. For example, if someone is lateralizing their center of gravity to the right, it will force their pelvis to rotate and their body to compensate in other other ways too. When we can’t activate certain muscles or joints properly due to compensations, we develop symptoms such as trouble breathing, backaches, neck pains and so on.

Over time compensations can start to “feed a pain-pattern.” In the words of those who perform postural restoration therapy, “whatever you load, you will reinforce.” For example, if you have poor form while exercising, you’re only further reinforcing your body’s harmful compensations. The more weight you lift, the more you develop ingrained movement patterns. If you already have an unhealthy movement pattern, adding weight usually only makes things worse.

5 Postural Restoration Benefits

1. Helps Lower Joint Pain

As described above, the underlying principle of postural restoration is to use exercises and techniques to address the body’s asymmetries. The human body is not symmetrical (the same on each side of the body), so there is not one dominant center.  There are many kinds of anatomical asymmetries that everyone has; when we use one side of the body more than the other, things start to get painful. Joints start to wear out sooner and breathing becomes compromised.

Certain muscles and joints can become overused, including the hip flexors, paraspinals and/or tensor fascia latae. Activating certain muscles can help decrease stress placed on susceptible joints. Exercises are used to help activate under-working hamstrings, gluteus medius and/or gluteus maximus muscles and others.

2. Improves Breathing, Performance & Endurance

Asymmetries of the diaphragm affect position and posture of the human body. By correcting the diaphragm’s position, one of the most important things that postural restoration can help improve is a patient’s breathing. Groups of muscles (or “muscle chains,” as they are sometimes called) manage how well air is used in the rib cage and chest well. Breathing can become shortened or problematic due to things like injuries, stress, pregnancy and compensations.

When breathing is compromised, the body deals with stress less effectively, endurance and stamina suffer, and other symptoms such as trouble sleeping or exercising may be experienced. Dr. George says that “Breathing is a hot topic right now in sports performance and elsewhere. If you’re not managing breathing, your core conditioning will be lacking in it’s most crucial component. As postural restoration therapists, we can test breathing and determine how well you’re managing stress, functioning and more.”

To help patients who are not breathing appropriately, practitioners will use exercises to help improve expansion of the diaphragms and reorient the sacrum and lumbar spine (often to the right). Exercises to improve breathing can include: Sternal Positional Stretch, 90-90 Supported Hip Shift with Hemibridge and Balloon, and Standing Wall Supported Reach. (1) There’s also evidence that similar exercises and/or manual therapy techniques can also be helpful in many cases of asthma, cough, and recurrent sinusitis or frequent infections. (2)

3. Decreased Low Back Pain

Low back pain is one of the most common problems that adults of all ages deal with. Causes can include inactivity, poor form when exercising, degenerative joint problems, pregnancy and, of course, poor posture. The position of the pelvis can contribute to low back pain in many patients, often by causing increased spinal torque in certain areas and rotation of the sacrum and lumbar spine (usually to the right).

Poor posture that contributes to pain back starts from the ground up, so exercises aim to help activate under-used muscles in the hamstrings, glutes, femur, hips and pelvis.  Treatments for low back pain can include exercises such as: 90-90 Supported Hip Lift with Hemibridge, Right Sidelying Respiratory Left Adductor Pullback and Left Side-lying Right Glute Max. (3)

4. Helps Reduce Neck Pain & Headaches

Both physically and neurologically, there are notable differences between two sides of the head and brain. The brain is asymmetrical, both physically and also in regards to the neurological mapping of the hemispheres of the brain.

Most people tend to be right-hand dominant, due to lateralizing more to the right. The skull then rotates to the left, which contributes to cranial strains (left cranial side bend). This can contribute to neck pains, headaches and cognitive problems. Postural restoration aims to help realign the spine and neck as much as possible, reducing pressure that leads to pain.

5. Helps Manage Scoliosis Symptoms & Progression

Scoliosis is a complex spinal problem that cannot be cured through postural restoration exercises, but can be better managed. Postural techniques can offer benefits for patients with scoliosis by reducing torsion and correcting mechanics of the rib cage. (4) The goal is to improve neutrality and stability of the pelvis.

Many patients need to work on achieving “left acetabular-femoral internal rotation or proper position for stability of the hips,” according to the PRI website. Others work on activating expansion of the right upper chest wall and a strong oppositional foundation for left diaphragmatic contraction. Early intervention is most beneficial, so ideally adolescents with scoliosis will begin seeing a practitioner before or during their teenage years to help stop progression. Scoliosis patients who use a brace, or a day and/or night jacket, can also visit a PRI physician to improve symptoms even more.

Postural Restoration Shoes and Orthotics 

PR therapists work with other doctors and practitioners to improve patient results. Examples include working with a neuro-optometrists, dentist or podiatrist. The Musculoskeletal Physiotherapy of Australia (MPA) association states that “These interdisciplinary relationships are based on the recognition and belief of PRC Physical Therapists in the relationship between posture and teeth, between posture and feet, and between posture and vision.”

Good posture starts with the feet, including the alignment of the big toe, and working its way up the ankle, knee, hips, pelvis and spine. Orthotics offered by the PRI help to re-align the joints of the foot, encouraging the muscles and tendons to pull themselves into a stronger, more appropriate position.  

PRI orthotics are highly contoured to the patient’s foot and provide stimulation of nerve endings. This allows sensory information to be sent from the feet to the brain, helping to encode the new position as part of “muscle memory.” While someone walks or moves forward, PRI orthotics flex with the foot throughout the gait cycle and keep the joints of the feet in their proper place, making sure the foot is aligned. (5)

Postural Restoration for Oral Alignment 

Once per week Dr. Cantrell does integrative work with a dentist. He helps to adjust the neck and to fix abnormal neck muscle activity or cranial abnormalities that make dental problems and breathing even worse. (6) According to Dr. Cantrell, “Within seconds we see positive effects and changes in test results. And this happens over and over again with different patients!” 

One way that postural restoration aims to improve oral alignment and dental health is by reducing neurological adaptations to compensations. If a patient wears a splint to help realign their mouth, the splint won’t be adjusted until both doctors (dentist and postural restoration therapist) agree it should, so it’s a really a team effort.

Postural restoration can also help decrease TMJ symptoms and headaches. It’s been found that these symptoms tend to occur due to craniofacial adaptations, forward head posture and overuse of certain muscles in the jaw and neck. Even abnormalities in the diaphragm and obliques can affect breathing that contributes to facial and neck pain.

Postural Restoration for Vision 

According to the PRI Vision Center website, after 35 years of practice, Ron Hruska, PT, “realized through clinical observations and study of older literature on the vision system that controlling input from the vision system might be the key to helping many people obtain a neutral (more balanced and relaxed) posture, relaxed neck and trunk, and pain relief for the long term.”

The PRI approach to using vision to rehabilitate the body works by reversing painful patterns of the vestibular (inner ear) and neuro-muscular systems. Parts of the brain and nervous system affected by vision include areas of human behavior, nerves that control posture and body position, and muscles of the trunk and spine, among others. In fact, 70 percent or more of the human brain is wired to the vision system, so vision affects many aspects of well-being.

Therapists use the Dynamic Integrated Vision Assessment (or DIVA) to evaluate how patients’ vision may impact their muscle patterns and functionality. The PRI vision center explains that when therapists 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. The proper communication between the brain and the body becomes embedded, providing long term relief.”

By decreasing muscular tension and musculoskeletal imbalance, PRI Vision treatments can be beneficial for a wide range of patients dealing with problems such as: neck pain, dizziness and balance problems, poor sleep patterns, fibromyalgia-type symptoms, jaw and facial pain, or chronic fatigue.

Popular Postural Restoration Exercises

There are as many as 350 manual and non-manual techniques (exercises) used in PR. Therapists may use heat and props such as balloons or balls to help patients perform exercises properly and increase flexibility. Most patients will need to be visit a therapist between 7–15 times to see improvements (sometimes less or more), with each visit lasting about 1–2 hours. Below are several examples of popular postural restoration exercises:

  • PRI Diaphragmatic Breathing — To perform diaphragmatic breathing, you want the abdomen to expand first, then the chest. Try not to use your neck and stiffness your shoulders. Breathe in through the nose and out through the mouth. Exhale twice as long as inhaling to engage your abdominals. Take these long, slow breaths for several minutes at a time, trying to breath about 8 to 10 times per minute.

  • 90/90 Hemi-Bridge — Position yourself on the ground with your back flat and your knees bent at 90 degrees, so your shins are parallel to the floor. While keeping your knees over your hips and back down flat on the floor, place your feet on a wall. Scoop your pelvis and lift the tailbone so your core is engaged. Take your right foot off the wall, straighten the leg and tap the foot slowly 10 times against the wall. Keep the opposite leg tight and bent, breathing deeply and slowly as you do this. Then switch sides. Focus on breathing through the nose rather than the mouth, then blowing out through the mouth.
  • 90/90 Hip Lift Ball Squeeze — Position yourself in the same way as when you’re doing hemi-bridges. Place a soft ball (or foam roller) between your knees that you will squeeze to hold in place. Pull your heels down to engage your hamstrings and engage your core. Peel your pelvis off floor and lift your tailbone. While you do this focus on your breathing, inhaling through the nose and out through the mouth. Shift your left hip down and right hip up, so your right knee is slightly above the left. Perform four sets on each side.


Postural restoration exercises - Dr. Axe

Patient Success Stories

Some of the many types of patients who have experienced improvements in their symptoms following postural restoration include:

  • Teenagers
  • Athletes
  • “Weekend warriors”
  • Baby boomers
  • Elderly patients
  • And people who exercise recreationally, including running, surfing, doing yoga, etc.

One young lady that Dr. Cantrell recalls successfully treated was a triathlete (she runs, bikes and swims) named Loukia Lili-Williams. Loukia was suffering from right lower abdominal pain that she couldn’t figure out how to get rid of. She had may different tests done — colonoscopy, MRI, pelvic ultrasounds, doppler (for possible blood clots), dry needling, saline, inflammatory cream and steroid injections — and tried many types of workouts and alternative treatments, including traditional physical therapy and massage therapy, but nothing seemed to help resolve the problem.

Loukia’s team of doctors and practitioners couldn’t figure out what the root cause of her symptoms was, so of course they kept coming back. It was discovered by her practitioner at PRI that she fit the bill of the “soccer players tug of war.” Her right obliques weren’t allowing her ribs on the right to externally rotate. Every time she stood on her left leg, her right ribs needed to externally rotate, but she couldn’t inhibit the muscles on the right in order to do this. When running she wasn’t able to increase breathing to meet her increased need for air because her rib cage couldn’t rotate. After many failed attempts at correcting the situation, following postural treatment she experienced great improvements in breathing, symptoms and her physical performance.

Dr. George recalls treating one woman who was an avid yogi and surfer. He uncovered that she was actually too flexible (a common precursor to yoga injuries), overusing certain muscles but neglecting to use others. Despite being very active, she was suffering from low back pain and couldn’t sleep on her side due to lots of discomfort in both shoulders as well. Ultimately she needed to learn to activate certain muscles in her core and to learn how to breath properly.

The rib cage determines the position of the shoulder blades, and breathing determines the position of the rib cage, so she was experiencing a variety of symptoms in her chest and shoulders. Dr. George helped to put her into certain positions in order to activate parts of her left side of the body, helping to keep her pelvis from turning too much to the right, and her rib cage from turning too much to the left. Her pain got much better with treatment and she was able to continue doing all of the hobbies she loved, without compromising her breathing or form.

PRI Certification Courses 

In order to provide a structure and network for clinicians and therapists to learn about postural therapy, the Postural Restoration Institute began offering certification courses in 2004. Currently PRI offers three introductory courses, three secondary courses and an annual symposium.

The five continuing education courses offered by PRI include those focusing on: Postural Respiration, Myokinematic Restoration, Impingement/Instability, Cervical-Cranio-Mandibular Restoration and Advanced Integration. All courses offered by PRI are two days long, with the exception of the Advanced Integration course, which is four days. More information regarding programs and courses can be found on the PRI website here.

Read Next: Neurokinetic Therapy — a New Way to Rehab for Injuries

Josh Axe

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