#33 - Understanding and Correcting Right-Side Bias, Part 2

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Hi guys, welcome to a new episode of The Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thanks for listening. Today we wrap up our 2-part training titled, Why Are You Always Right? Understanding and Correcting Right-Side Bias with Beth Keis. In episode 32, Beth explained how balancing the body requires both sides working together and the important role that breathing serves in maintaining pain-free movement. Today, we continue this discussion and dive into the causes of right-side bias and how it contributes to the loss of intra-abdominal pressure. We'll also discuss the implication of this bias on performance and activities of daily living, As well as the importance of developmental multiplanar movements to prevent this phenomenon. Beth Keyes has dedicated her career to helping people attain maximum physical fitness and healthy function. After suffering multiple injuries in an auto accident, undergoing surgery, and receiving traditional physical therapy without great progress, she embarked on a mission to help others achieve optimal fitness for their life goals. Beth considers herself a tireless researcher Providing the very best information to her clients based upon their specific needs and the latest research. She has her master's in education, has trained in the Postural Restoration Institute methods, and is a DNS exercise-trained practitioner. She's also a certified strength and conditioning coach and a certified golf biomechanist. Now let's cue the intro music and get started.

So let's go ahead and take a look at our most popular weight training exercises again. Remember with the squat, well, if I'm stuck in right stance with a hip that's posteriorly tilted right and anteriorly tilted left, as I drop down, my seat is going to go right with gravity, go right with that heavy side of my body. I'm actually going to squat over and down towards— closer towards the right foot. The same is going to happen in a hip hinge or a deadlift-type exercise. With that limited right hip flexion, The body is going to move a little bit closer over to that right side. With the tight left lumbar erectors, usually what happens is that someone goes to return to standing from that deadlift, they do so by extending the left low back, which can cause left low back issues. In bench press, remember we talked about that right shoulder being higher and forward, having a limited internal rotation. So we could be looking potentially at impingement issues with that right shoulder. In rowing, biceps curls, triceps extension, these guys love to stabilize with that, just that low back. So all the rowing is accompanied with lumbar extension. Bicep curls are accompanied with lumbar extension. Remember, we have limited shoulder flexion as well, which helps to get that low back kicked in. And these guys love to line up with that low back fully extended as they try to work in tricep extension. And so My question is, if we know that we're kind of— we have this bias to right stance, and we know that we need to be pushing ourselves to the left, why do so many of our programs rely so heavily on single-planar exercises which keep us, or try to keep us, equal on both feet? What we really need to see more is an introduction of transverse plane and coupled with Sagittal and frontal plane. You know, things like wood chops and reverse wood chops, push-pulls with rotation. However, I of course would not be giving that to our previous client that we've been talking about, stuck in that right bias position. We want to get them out of that right bias position first. Over a prolonged period of time, some of the things that can start to occur as you're stuck in this right stance with the right head being over, there can be neck pain, jaw, tooth grinding on that right side. There won't be much molar contact on that left side. Again, we talked about shoulder anterior impingement. Left side, we're talking about more of a biceps tendon impingement. Overuse of the elbows because the torso doesn't rotate well and we know that the shoulders do not rotate well. So we're looking at oversupination and pronation of elbows to try and complete movements, much like throwing. For the right side, hip pain and replacement. With all that excess weight being on that right side, That right hip joint wears out too. And I think you could probably throw in knee replacement as well. On the left side, being in that extension, a lot of low back pain, that constant hip flexion and lumbar extension can also lead to hip groin pain on that left side. For the right side, lateral knee, IT band, again, everything's kind of shifted over, that the hip is adducted. And as that weight comes down onto that right side, that hip will adduct even more, causing strain and tension On that IT band. On the left side, we know that the— with the weight being mostly forward on the toes, a lot of anterior knee pain, and then also medial knee pain with the bias towards the inner heel. On the right side being in right stance, we know that we're already halfway there to ankle sprain. The left side will be more of an Achilles or a calf strain. On the right side, as we try to start to walk, that's where you start to kind of get a bunion on that big toe. On the left side, being on the toes, the toes will curl forward and tight and turn into hammer toes. Depending upon how comfortable you are with your client, you can take a look at things like feet and all that other stuff to see just how long they've been in this position or this— in this compensation. And so this is why it's so important to really give a good look to your clients, to assess them, to see where they are in their biases and in their processes. It's certainly, it's important to discuss any kind of previous injuries or current aches and pains. Definitely an ACL reconstruction on the left can instantly push someone to a right-side bias, particularly as that knee is healing and they're starting to get to use it again. So all of these kinds of questions are really important. The visual postural deviations from the midline and from right to left provide some very important clues as to where they're sitting, what muscles are working too hard, what muscles are not working hard enough. And then, of course, to measure and compare from both right side to left side and to normal. Things like shoulder flexion, internal and external rotation, your torso rotation, hip flexion and extension, AB and adduction, internal rotation, and of course knee extension with ankle dorsiflexion. So, and only after you've done a thorough evaluation and then been able to identify any of these postural deviations, musculoskeletal deviations, and then breathing, of course, intra-abdominal pressure, and you correct that.

Okay.

Should they really begin or continue any kind of training program? And hopefully that program will include counterbalancing exercises that encourage right with left and left with right movement and moving into forceful push to the left. So for me, I always want to talk about correction and intra-abdominal pressure and the diaphragm and the psoas relationship. We had our diagram earlier, and we know that this is really important because the diaphragm not only helps to decompress the lumbar spine, It also presses the organs down in towards the pelvis to provide stability to the lumbar spine, provide positioning for the hips as well. It also, as we talked about, is a very powerful counterbalance to the strong psoas. The psoas is a hip flexor and it can only draw the lumbar spine forward. It's really important for the crus of that diaphragm to be able to have a forceful draw down so that it can pull up on that crus to counterbalance that. Unfortunately, when that starts to break down and the psoas becomes the de facto stabilizer, mostly what it does is to draw the low back into extension and our pelvis into hip flexion. So here we have, you can see here the importance of the alignment of the diaphragm and the pelvic floor through these images. Musculature on the front side would be provided from the transversus abdominis, and then the backside of the spine would be the multifidus. In our bilateral anterior tilt, you could see how the diaphragm comes up. And the pelvic floor goes down and back. Right stance would be kind of our middle where the diaphragm is kind of down, the pelvic floor is down, the abdominals are still not functioning right. And then of course, over time, as we require more oxygen, we are not even necessarily able to get it. Our head starts to come forward, our upper back starts to round. I just didn't want you guys to think that right stance was the only adaptation that was made. And There are several adaptations that come about as a result of being in, well, prolonged right stance, but not being able to have a functioning diaphragm and pelvic floor and inner unit to provide this intra-abdominal stability. So we know that a full and complete contraction of the diaphragm is essential to counterbalance the downward pull of the psoas. When the diaphragm cannot fully contract, it weakens and this pelvis and spinal stabilization is lost. The absence of the diaphragm-psoas balance The psoas will always win. It has more attachments. It's stronger. So it will take over for the diaphragm and then cause bilateral anterior tilt. And so if we revisit our original discussion about the breath and our right stance, as that right rib cage cannot expand in the front, the diaphragm does weaken over time. And again, with the diaphragm not being able to pull down, it's not drawing up on the crus ligament to decompress the spine. And of course, we have on that left side, same thing, diaphragm is up, the psoas has already taken over. If you can imagine, as I'm in right stance, my body kind of wants to get back to a sense of normalcy, for lack of a better term. So as it's trying to kind of reorient my head back to the middle so I can see properly and try and get me to turn to the left, it's also going to start to draw those right ribs upward and into that— So into that psoas stabilization, right rib up. So the right and the left side are going to look much alike in this bilateral anterior tilt. And so this is what being in right stance over a really long period of time and challenging yourself can lead to. But this is a discussion for another day, another day, another lecture. And I would argue that for as many individual people as there are, there are the same amount of individual adaptations that can occur. And health history, things like previous injury, scar tissue, things like that all play a really important part in how we adapt and how we change and how we try to deal with our asymmetrical inside and getting back to the left and being able to function right with left and left with right. So for me, when I start to talk to clients about correcting this, I always start with breath first, rib position, especially Especially as it relates to belly button and pelvis position, making sure that low ribs can inflate properly and expand properly to reestablish that IAP, intra-abdominal pressure, which provides the basis and the stability for the rib cage, the spine, and then the pelvis. And then once we can get the pelvis and everything aligned, we can start to deal with the muscular imbalances that are caused, whether it be that you're addressing the overactive adductors, hip internal rotators, and extensors on the right. By recommending exercises that do the opposite, that abduct and externally rotate and flex that right hip. And then for the left, the opposite, because it is abducted, externally rotated, and flexed. We want to make sure that we recommend muscles and exercises that will look to bring it into extension, adduction, and internal rotation. And once again, all once we have that abdominal muscles working properly, left ab nice and strong. ribs aligned and have reestablished good pressure and relationship between the diaphragm and the pelvis. And once that is done, now we can really talk about training client and producing successful outcomes as a result of working with them and their natural biases. So thank you guys very much. I look forward to your questions and happy Halloween. Thanks for joining us.

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Thank you so much, Beth. That was a great presentation. So one of our questions was, Someone was curious if the right-side bias favoritism is predominantly for right-side dominant people, or do you see it across the board with left-handed and right-handed population?

It is absent dominance, which is what's so interesting about it. And in fact, some of the most complex cases that I have had have been people who are left-handed but are clearly stuck in right-side dominance. It really has to do with the weight of the organs and the venous return on that right side, with that liver being heavier on that right side, and has nothing to do with the handedness, footedness, or eyeness. So while the challenges are slightly different between a right-handed person who's in a right stance bias versus a left-handed, the approach is very similar. But yes, I've had multiple, multiple clients who are left-handed and left-footed. Totally stuck in a right bias pattern.

Very interesting.

What— and this kind of goes along through that same thought process— have you found, especially because you work with a number of athletes, do you see more of these presentations in athletes that have a hand dominance in terms of how they play? So for example, your baseball players, your golfers, your tennis players who are constantly going through this same motions, mainly utilizing one side of their body versus another, one arm, one hand, swing a certain way. Do you find that that factors into this at all?

For the— for a right-handed player, it's very easy and natural to get stuck in right stance bias because every way that they set up, so whether it be the golf swing, as you take your backswing, you're in right stance bias. If I have— if I'm holding a baseball bat and I'm going to go into my stance, I'm going to end up being in right stance bias. So it's very, very interesting to see that, that they can get easily stuck. A left person who swings left and right stance bias has a difficulty completing. Remember we talked about not being really able to rotate to the left, being predisposed to extending the lumbar spine. So as they kind of swing through, they start to—

Whee!

Extend at that low back area instead. Just, you know, so as they're, as they're kind of lining up, they're already in extension and not really able to rotate back, and they end up overfinishing on the right. So like I said, even though the performance issues are slightly different, the results in the way the hips function, the way the shoulders function, and the way the elbows frequently— shoulders and then elbows take a beating— function are very similar.

Wonderful. Are there any books that you would recommend or additional type of like research articles that you would recommend for our listeners to continue learning more about this topic?

Well, absolutely. If this right stance bias was really the brainchild of Ron Hruska at the Postural Restoration Institute. So I highly recommend going there. You can even just Google some of their articles. They offer courses, which are amazing. But yeah, lots and lots of printed information about this right stance bias. And then of course, the idea of The diaphragm and the psoas relationship, the pelvic floor relationship, that intra-abdominal pressure is— Pavel Kolar and Dynamic Neuromuscular Stabilization has really done a great job, has published a lot of articles on that. And in fact, some of them are in the resources notes of this lecture as well, different articles that I've pulled this information from. Absolutely.

Wonderful. When it comes to your patient assessments, and I know you were talking earlier about when you're working with someone new, you always try to dig deep and ask questions about past injuries, things that might be contributing to what they have going on. And so often we hear from practitioners that people forget, oh yeah, I broke my ankle when I was in 3rd grade, or there was this one time where I broke my femur and I had to be in traction for a certain number of months or whatever, because it was so far back. What tips or advice or guidance do you have for practitioners to make sure that they really are getting the full story on any past injury that could possibly be relevant.

So I have to say that I used to have this extensive questionnaire that I would send. It was probably like 4 pages long and invariably would come back with just lines through it. No, no, no, no. So I had to— and always that would happen. Your client would come and say, oh, this is a little limited. Oh yeah, I remember when I broke that or I sprained that or So now I just sit down and I talk to them. When they first come in, we spend the first 10 or 15 minutes just talking about their life, what's going on, why'd they come, any aches and pains, what kind of sports they were involved in as a kid. I find if I sort of take them backwards chronologically that they do a little bit better job remembering. It's like, oh, so when you were in college, what sports did you play or what did you do? Or, oh, did anything happen? And Well, how did you get involved in that sport or activity? Did you do it in high school? But it still occasionally, someone will come and be like, I go through something and then they'll say, oh yeah, that's right. 15 years ago I did this. So it still does happen occasionally, but I do think sitting with them, talking about the present and working your way back through experiences helps them to remember a little bit better.

Absolutely. And I know that again, sometimes patients, they think that it's not relevant. They think, well, you have low back pain. Why does it matter if I turn my ankle 7 times when I was playing basketball in high school? Like—

Right.

So I think that was a very important point, like trying to continue that conversation. And, and you are, in many ways, you're kind of a detective trying to find the diamond in the rough, so to speak. When it comes to these clients that are having issues with right-side dominance, I know you had touched a little bit on breathing. And some of the making sure that they really have that great stability and are providing that intra-abdominal pressure. How often are you finding like issues like paradoxical breathing going on with these clients? Is it kind of an almost every single time you're seeing right-side bias, you're also seeing breathing issues? Yes.

And I would say that just about everybody I see has some kind of breathing disorder. It's really amazing. In my lecture series, I talk about— there's a fabulous quote from Eric Dalton, who's a Rolf era bodyworker who studied with Ida Rolf. And he said, we breathe 21,000 times a day and it's our most dysfunctional pattern. So everyone that I see has some kind of breathing dysfunction, whether it be very shallow breath, like a 2 or 3-second inhale and an exhale. Frequently, both ribs are elevated so that they're only breathing with the chest. Some of my athletes who are trying to get rid of that, that sort of shallow chest breathing, who know that they should belly breathe, unfortunately end up tamping down the low ribs. And then what happens is that the belly expands underneath, but the ribs don't expand. That's a phenomenon I call bullfrogging because it literally looks like the mouth of the chin of a bullfrog. This is all strapped down. And then as it goes, whoop.

Bloop.

So, and getting them to— these are my guys that are really stuck in lumbar extension, that it's a phenomenon that Paul Hodges calls long lumbar erectors. So that they are— their low back has been in extension for so long that it's extended all the way up the thoracic spine. So the ribs no longer expand, the back hardly wants to move, and all they can do is just kind of open up that area underneath the ribs to try and get air in. Yeah, they're challenging to work with because they really need to be in flexion and, oh, they don't like it. They shake. Their abdominals are so weak from being pulled long. So, but yeah, I would say everyone that comes to me does have a dysfunctional breathing pattern. And I always start with it because believe it or not, a lot can be resolved just by working with the breath.

And that was my next question. So that makes a lot of sense. And I have heard that and we've talked about that in a variety of different rehabs lectures and webinars that we've had is just the importance of looking at the breath. And how do you approach that with your patients in terms of that conversation? Is that just a standard protocol that you go through with your intake and your assessment? And how do you have that conversation with them so that they're not like, well, I don't understand, like, I'm having issues here, why are you talking about my breathing?

I finish my assessment with the evaluation of their breathing. And I ask them just to perform some basic abdominal exercises. And when they're not able to do those, it's really kind of an aha moment for them. And we're talking like a basic kind of dead bug where they have to keep the low back flat, just asking them to raise their knees up over their hips without arching their backs. And they're like, wow, I, some, in some cases, I used to be able to do that and I can't anymore. But then it becomes a conversation of, well, why can't I do this? And so then I will ask them to get into like slightly different positions, like a bear pose or all 4, rounding. And they find that, oh my gosh, I can't get my back up. I can't do, I can't even, I'm feeling all these weird pulls in all these different areas. So that's why taking, having people move during your evaluation, getting them to compare like right external, right and left external rotation and internal rotation. So they can feel like, oh wow, that left leg really turns way out more to the left than the right one can. It becomes a discussion then. So that's why it's not just enough to look at the posture. It's not just enough to take a few measurements. It's really good to get them involved in that process and get them to feel the differences. And then they start to get the idea that, yeah, it really is all connected.

Absolutely. And I think that is something that we've had emphasized over and over again, especially when it comes to any kind of movement-based therapy, is if people can connect to their body, if people can feel the differences between one side and the other, that really, I'm sure, kind of locks it in for them.

Mm-hmm.

That being said, when it comes to working with athletes, especially those that are like CrossFit-style athletes or those that are used to doing these WOD-type exercises or EMOMs where they're trying to do the fastest number of reps in a certain time period. How do you help them retrain their thought process about, okay, we need to have your body move in different planes of motion and doing it as fast as humanly possible with the heaviest weight possible is probably not the best idea. How do you approach those conversations?

In some cases, I'm a bit of an Instagram stalker. I work with a lot of trainers, and so they're posting all these lovely videos of them performing these exercises, and I'll actually screenshot them so that I can show them—

That is wonderful.

What they actually look like while they're doing it. And it's hysterical because they say, oh my gosh, I had no idea my back was like this.

Yeah.

But no, I do ask them for my clients, some of them to send video of them either doing exercise I recommended or that they're doing. And so that I can go through it frame by frame with them. For my golfers, my tennis players, they'll show, send me videos of them actually playing and we can go through them frame by frame.

Nice. And I think too, I know a lot of practitioners will use some visual video and some cueing. There's some great softwares out there that will help help allow you to draw on different videos or make notes and send to your clients and your patients. I know those can be really helpful because likewise, I know that the visual feedback component is important.

Okay.

Do you have mirrors in your office? Do you usually start out by taking— I know you had some photos in your presentation. Do you use those visual representations to show people, okay, this is what I'm seeing and I want you to see the that there is some leaning here, or this shoulder's lower than this one, etc.

Yeah. And I have them do that particularly with like a forward bend because I can take a picture of that and show them what it looks like. And then after we do the correction, I take it again so that they can see the difference. The same thing with the squat. And also, oh my gosh, my favorite is the— is just the all-four belly lift or the bear pose. When you get them on all fours and ask them to round their back, and the first time they do it, it's like this, perfectly straight. And then by the time they're finished the correction, they can actually round their back. So yes, I do do that. But my assessment also provides a lot of instant feedback as well in going through the different activities that I ask them to do. There are clearly things that I know that they will not be able to do until after we perform the correction. And so it's like a huge aha moment when they can't lift their left knee up off the table laying on their left side. And then all of a sudden it flies up like no problem. They can lift. And it's always amazing because I have people who look at me and go, Is that supposed to come up? Is that supposed to move? And I'm like, yes, and I promise it will before you leave this room. And then they look at me—

That is awesome.

Okay, if you— are you sure? I'm like, I promise.

Very cool. Well, wonderful. If you are joining us for the first time and you're like, holy cow, these webinars are awesome, I cannot believe I didn't know about this before, welcome. We're excited to have you. We'll usually host at least one per month. And all of these webinar episodes are also broadcast through our Factor Podcast. So the Factor Podcast is available on Apple Podcasts, Spotify, iHeartRadio, or anywhere that you listen to your podcasts.

You can tune in anytime and hear the audio recording from these past webinars.

Beth's webinar here will be taken and split into 2 different podcast episodes, kind of a part 1 and a part 2. And even through our podcast, we also have a link in the show notes every time where you can submit questions. So after the podcast episodes air, we invite all of our instructors back on for a Q&A episode for our podcast where we'll go through some more questions that have come in from our podcast audience. So we really hope that these are informative and educational for you guys and just a great way for you to get some new clinical skills and build some knowledge. Again, Beth, thank you so much for your time today. This is an incredible presentation. And I know it's got a lot of people looking at things in a different way, and hopefully has provided them with some great clinical pearls that they can take back into practice.

Thanks so much, everybody. Thanks, Jessica.

That's it for today's episode. Be sure to tune in for episode 34, Where we feature a special Q&A episode with Dr. Todd Riddle and discuss his recent experience treating athletes at the World Games. You won't want to miss it. Episode 34 drops in 2 weeks. In preparation for our interview with Dr. Riddle, we have a special Q&A form linked in our show notes. Be sure to click the link and ask any burning questions you may have so we can be sure to ask them during the interview. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, Or the podcast app that works best for you. Please give us a 5-star rating to help us grow the show.

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