Where It Hurts
Aligning your patients (and practice) with the Gokhale Method™
By Cheri Boeckmann, PT, BS
October 3, 2010

I have been a physical therapist for more than two decades, regularly attending seminars and courses to keep current on outpatient topics through APTA continuing education courses. But the most significant changes to the model I am using when teaching posture and functional movement, have come from a method outside the traditional PT realm. This method was developed by Esther Gokhale, whose work has significantly altered my notion of “normal/neutral” posture, modified the delivery system of my services, and enhanced the patient experience in my clinic.

My history with the Gokhale Method started by word of mouth from a patient, evolved into my becoming a student, grew into a personal daily embodiment of the postures and techniques, and then became integrated into my livelihood after training to be a Gokhale Method Foundations instructor.

Today, I continue with my Gokhale-enhanced physical therapy practice, complimented with teaching group or private Gokhale Method Foundations (GMF) courses. My GMF and PT practices complement each other to bring a new level of health to my clients. The combination of private and third party payments bring a new level of health to my business. I highly recommend that physical therapists consider training in the Gokhale Method.

Introducing the Gokhale Method

The Gokhale Method is an approach to preventing and eliminating musculoskeletal pain by restoring healthy posture and movement. When everyday movements, such as walking, bending, standing, sitting, and sleeping are performed optimally, muscles are strengthened and joints are protected well into old age. The Gokhale Method is based on historical, anthropological and medical research on populations who have virtually no musculoskeletal pain: ancient and tribal cultures, babies and toddlers, and Americans before the 1920s.

The Gokhale Method is taught through two primary sources, a short series of classes and the book, 8 Steps to a Pain-Free Back. In both resources, Esther Gokhale chronicles her approach and presents her techniques in logical and systematic lessons. In the Gokhale Method Foundations course, groups of up to eight students are taught in six 1.5 hour-long sessions.

Many students experience pain relief after the first lesson; long-term success is also high. Student follow through is consistent because many of the techniques provide immediate relief and because no equipment or exercise time is needed. Some students come to the Gokhale Method Foundations course through physician referral; most students discover the Gokhale Method through word of mouth and the media.

Physical Therapy Compared with the Gokhale Method of Teaching Posture

As physical therapists, we are considered experts on posture and the biomechanics of functional movement. Both of these topics are typically included in neck and back pain rehabilitation programs. The majority of these patients have postural abnormalities contributing to or causing pain symptoms. Spinal hyper-mobilities are common, routinely indicating the vertebral levels most symptomatic from misuse.

Hyper-mobilities often correlate with hypo-mobilities at other spinal levels, or with decreased range of motion (ROM) at the ball and socket/tri-axial joints of bilateral shoulders and hips. For example, if pectoral muscles are taut, reaching overhead results in spinal extension, increasing segmental mobility. If hamstrings are taut, bending forward results in posterior pelvic tilt and spinal flexion, again creating spinal hyper-mobility. Exercises to strengthen or stretch specific muscles are a common approach for correcting posture, but many physical therapists and their patients find this method difficult, frustrating, and time-consuming.

The Gokhale Method instructs positioning the pelvis and the legs so the spine can straighten, the shoulders can relax back and the neck can stack effortlessly.

In addition, targeting one or two body parts is usually not sufficient for postural correction since the positional relationships of body segments are deeply connected. Often, improving the alignment of one part of the body exacerbates abnormality in another part, requiring a “see-saw” approach. For example, positioning the scapula in greater posterior depression often results in exacerbation of lumbar lordosis, while correction of lumbar lordosis often results in protraction of the shoulder girdles.

The Gokhale Method, on the other hand, is an educational approach that addresses the root of the musculo-skeletal relationship. Students relearn the foundation of common movements. For example, rather than attempting to hold the neck straight in isolation, students learn how to move from the bottom up, thus doing away with learned habits and establishing a healthy baseline. This is taught through functional movements where students learn, for example, healthy sitting, including stack-sitting, stretch-sitting, how to use the chair, and where to position the pelvis and the legs so the spine can straighten, the shoulders can relax back and the neck can stack effortlessly.

Defining the Posture Model

Healthcare providers often disagree about what optimal posture is and how to sustain it. As physical therapists, we sometimes make postural decisions without knowing the logic or reason behind them. Sometimes our approach is based on learned conventional wisdom.

The conventional advice to correct protracted slumped shoulders is to instruct patients to reposition the scapula through contraction of the rhomboids. While this may lead to temporary correction, patients often return to old habits due to muscle fatigue. Asking these weak, overstretched, and mechanically inefficient muscles to work against tight pectoral muscles is not a sustainable model. With this approach, patients usually alternate between tense muscles or a slumped back, neither of which is healthy.

The Gokhale Method includes a technique called the shoulder roll (free download available at http://www.egwellness.com/sites/default/files/pdf/shoulder_roll.pdf), wherein the student realigns the shoulders by rolling them back, as if ratcheting the shoulder soft tissue back one notch on a cogged wheel. The shoulder can remain in this position with little muscular effort, unless working against extremely tight pectorals.

Consider the word “neutral,” as it is used to define the ideal position of the pelvis with respect to the spine and bilateral hip joints. What exactly is “neutral”? I have been following a neutral model that was defined as bilateral asis and pubic symphysis aligning on the same frontal plane. In fact, this pelvic alignment was illustrated on a recently purchased educational clinic poster portraying the skeletal system. But Gokhale considers this “neutral” pelvis to be an unhealthy and unnatural position that lends to either relaxed and slumped or upright and tense posture. Pelvic anteversion and the accompanying relaxed and upright spine is a key teaching of the Gokhale Method. [image: stacksitting]

Evidenced-based?

Principles like the anteverted pelvis are based on historical and anthropological observation of people in non-industrial cultures. Supporting evidence of these claim includes anatomical observations and arguments (the l5-s1 disc is wedge-shaped, pelvic anteversion places the gluteal muscles in a position of mechanical advantage), as well as findings in the medical literature.

For example, the study by Jackson ND McManus reporting that patients with back pain have increased upper lumbar lordosis and diminished pelvic anteversion whereas subjects with no back pain have flatter upper lumbar spines and significant pelvic anteversion).

A formal study in the effectiveness of the GMF course for chronic low back pain patients who have failed PT is scheduled to begin in March 2011 through the Palo Alto Medical Foundation.

Learning Posture

Regardless of what postural model we are using, learning must occur in order for healthy alignment to be assimilated into everyday activities. As physical therapists, we have under-recognized the importance of emotion, aesthetics and art in teaching our patients.

To communicate effectively with our patients, we need to use their language, stimulate their thinking, get “buy in” to what we have to offer. Too often in patient communication we are speaking “at” our patients, not reaching the emotional elements that make postural work individually desirable.

The Gokhale Method Foundations’ course has been carefully choreographed to persuade and educate by tapping into the visual, intellectual, aesthetic, and artistic aspects of our humanness. Although not an educational model traditionally used with our patients, the Gokhale Method’s use of images in small group settings, verbal instructions, demonstrations and tactile feedback interweaves multiple layers of postural stimuli, compelling patients to identify with what is considered the natural or primal posture of human movement, worthy of emulating.

Part of Your Practice

Although the Gokhale Method is a departure from the postural model many of us were taught, there are many benefits of integrating it into a physical therapy practice.

I have personally observed the truth of these teachings. During my travels, I have had the opportunity to observe the cultures in which activities of daily living consist of extensive manual labor, people standing and walking while carrying baskets on their heads and children on their backs, demonstrating an effortless elegance we rarely see.

The Gokhale Method introduces these techniques in a clear, sequential, logical approach. Physical therapists are in a position to understand, interpret, and teach this postural transformation to their patients. It is an opportunity proactively to prevent and treat back pain during initial phases, to front-load intervention strategies before the herniations, stenosis, and spondylosis occur. As an added bonus, the group logistic and private pay features provide welcome additional income in modern-day challenged PT practices. I strongly urge you to open your eyes, thought and practice to learn more about the Gokhale Method.

For more information, visit www.egwellness.com or pick up 8 Steps to a Pain-Free Back: Natural Posture Solutions for Pain in the Back, Neck, Shoulder, Hip, Knee, and Foot in your local bookstore.

— Cheri Boeckmann, PT, BS in Education, has been a physical therapist for 25 years and presently owns a small rural private practice in Lovingston, Virginia. After teaching physical education in Australia many years ago, she traveled through Southeast Asia, India, and Nepal, and was struck by the movements and postures of traditional cultures.

As a Gokhale Method Foundations instructor, she intends to help introduce Gokhale’s work to the PT community, to teach and share Gokhale’s techniques to facilitate self-responsibility, to reverse the current postural trends, and to promote preventive care.

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