GPR Dossier

GLOBAL POSTURAL REEDUCATION, A REVOLUTION IN MANUAL THERAPY

CONTENTS INTRODUCTION ................................................................................................. 3 A WORLDWIDE EXPERIENCE ................................................................ 4 CLINICAL AND SCIENTIFIC SUPPORT HOW TO EVALUATE USING GPR

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HOW TO TREAT USING GPR ..........................................................................7 NEUROMUSCULAR REPROGRAMMING IN GPR TREATMENT .................... 8 BIBLIOGRAPHY .................................................................................. 10 INTERNATIONAL TRAINING IN GPR .......................................................13 OVERVIEW OF GPR TRAINING ............................................................ 14 2

Global Postural Reeducation (GPR) is a physical therapy method developed in France by the physical therapist Philippe Souchard. This therapeutic approach is based on the concept of integrated neuromuscular coordination systems.

The GPR concept allows an evaluation, diagnostic and treatment different pathologies and dysfunctional postural or sport patterns in a innovated way.

With GPR it is possible to achieve goals in two principal ways: • Postural or morphological disorders as (hipercifosis, hiperlordosis or scoliosis) • Musculoskeletal pain and dysfunctional disorders.

Disorders of this sort are accompanied by muscle shortening, which can result from constitutional, behavioral and psychological factors

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A WIDE-WORLD EXPERIENCE This method is widely used throughout North and South America, in countries such as Canada, Argentina, Brazil, Chile, Uruguay Mexico. In Europe, it is an important part of physical therapy training in Spain, France, Italy, Portugal, Luxembourg, Belgium and Switzerland. Every year, hundreds of physical therapists are trained in RPG in 25 countries.

Physical therapists can receive a certificate by completing GPR training at the following universities: • Université de Montréal (Canada) • Universidad Rey Juan Carlos (Madrid, Spain) • Università degli Studi di Roma “Tor Vergata” (Rome, Italy)

SPAIN CANADA

Europe

ITALY PORTUGAL LUXEMBOURG BELGIUM SWITZERLAND 4

America and South-america

FRANCE

ARGENTINA BRAZIL CHILE URUGUAY MEXICO

CLINICAL AND SCIENTIFIC SUPPORT A literature review on GPR suggests that this method may be effective at treating some musculoskeletal diseases and disorders such as ankylosing spondylitis (Fernandez de las Peñas et al., 2005 and 2006) and lower back pain (Bonetti et al., 2010; Vanti et al., 2007).

Pilot studies have been carried out in patients s erin r fi r yal ia ar es et al 1994), patellofemoral pain syndrome (Cabral et al, 2007), stress urinary incontinence (Durmus et al, 2009; Tavares et al, 2009), chronic neck pain ren et al an re ce p l nary function (Alonso-Blanco et al., 2009; Durmus et al., 2009).

The GPR method showed a rapid increase of cortical inhibition after postural changes in a study evaluated with paired transcranial magnetic stimulation (Oliveri et al., 2012), which is i p rtant t c nfir the e ect P n motor system excitability.

GPR (Global Postural Reeducation) is a form of evaluating, diagnosing and treating conditions affecting the neuromuscular and musculoskeletal systems.

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HOW TO EVALUATE USING GPR The GPR method presents an innovated way to evaluate musculoskeletal disorders in hi h e ficient syste • A very precise global postural examination which observes the antigravitatory strategies in the subjets, the symmetry or asymmetry in head, shoulders or pelvis, and the t nic scles patterns • An examination of the adaptative and defensive patterns folling a soft manual c rrecti n the ys ncti nal patterns This techinque allows the physiotherapist to verify the correlation between possible origin and antialgic patterns • An examination in different positions to determine the adaptability of the neuromuscular system to different postural requirements • An assessment of function and movement to verify the coherence between the tonic postural syste an phasic ve ent patterns Years of clinical experience have shown that RPG provides an effective way to correct l cal an l al ve ent patterns 6

After years of clinic experience it can be establish a better follow up of results in the contemporary corrections of local and global patterns”

HOW TO TREAT USING GPR GPR is a proprietary inhibition method. By taking advantage of viscoelastic creep to achieve passive stretching, and combining this with isometric muscle contraction, a neurophysiological response inhibition is achieved.

Variations in posture are known to affect muscular tonicity and limit or enable manual joint correction. In GPR, it is important t st y the in ence p st re an apply this knowledge to treatment.

GPR involves the orthopedic manual therapy int isali n ent in specific p siti ns thereby simultaneously stretching the muscular and fascial systems. What is unique to GPR is the adjustment of dysfunctional joints (micro-correction) using a global postural ificati n hich lea s t a ificati n in muscle tone (macro-correction).

There is important respiratory work involved in GPR treatment positions in order to engage the postural functions of the diaphragm muscle, the a inal all an the ltifi s eep muscle. Improving the pulmonary and respiratory system has important effects on postural ree cati n an t nicity c y ie et al li iene et al 7

NEUROMUSCULAR REPROGRAMMING IN GPR TREATMENT

WHAT ELSE IN GPR TREATMENT? After the manual therapy of the musculoskeletal system, it is necessary a motor control reprograming targeting cortical changes movement organisation with special interest in patients with chronic pain. Specially in these patients it is very important to develop a precise and intense work in mapping the primary sensorial cortex in order to act over the imprecision in the cortical maps as neuroscience recomends (Boudreau et al, 2010; Moseley et al, 2012When treating these patients, it is especially important to precisely map the primary somatosensory cortex, as recommended by neuroscientists (Boudreau et al., 2010; Moseley et al., 2012).

HOW IS the TRAINING IN GPR? asic P trainin is str ct re ar n ďŹ ves seminars. Physical therapists can then go on to advanced training.

Course A: INTRODUCTION TO GLOBAL CONCEPTS IN PHYSICAL THERAPY USING GPR WHO DOES THE GPR TRAINING TARGET? The GPR training targets physical therapists.

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BIBLIOGRAPHY • Apuzzo D, Franzini M, Di Lucente L, Gioia MC, Cerasa A, Sabatini U: Combined Effect of O2/O3 and GPR in Treatment of Lumbar Disc Herniation: Anatomical, Clinical and Patient Self-Report Evaluation.

Eur J Clin Invest 2003, 33(Suppl 1):46.

• Bonetti F, Curti S, Mattioli S, Mugnai R, Vanti C, Violante FS, et al. Effectiveness of a “Global Postural Reeducation” Program for Persistent Low Back Pain: a Non-Randomized Controlled Trial. BMC Musculoskeletal Disorders. 2nd ed. BioMed Central Ltd; 2010 Dec 16;11(1):285.

• Boudreau SA, Farina D, Falla D. Manual Therapy. Elsevier Ltd; 2010 Oct 1;15(5):410–4. a ral i acc asar tt ar es P fic cia e as t cnicas e al n amento muscular no tratamento da síndrome femoropatelar: um estudo comparativo. Fisioter Pesq 2007, 14:48-56.

• Cunha AC, Burke TN, França FJ, Marques AP: Effect of Global Posture Reeducation and of Static Stretching on Pain, Range of Motion, and Quality of Life in Women with Chronic Neck Pain: A Randomized Clinical Trial. Clinics 2008, 63(6):763-70.

• Durmus D, Alayli G, Uzun O, Tander B, Cantürk F, Bek Y, Erkan L: Effects of Two Exercise Interventions on Pulmonary Functions in Patients with Ankylosing Spondylitis. Joint Bone Spine 2009, 76:150-155.

• Fernandez de las Peñas C, Alonso Blanco C, Morales Cabezas M, Miangolarra JC-Page: Two Exercise Interventions for the Management of Patients with Ankylosing Spondylitis: A Randomized Controlled Trial. Am J Phys Med Rehabil 2005, 84(6):407-19.

• Fernandez-de-Las-Peñas C, Alonso-Blanco C, Alguacil-Diego IM, Miangolarra- Page JC: One-Year Follow-Up of Two Exercise Interventions for the Management of Patients with Ankylosing Spondylitis: A Randomized Controlled Trial. Am J Phys Med Rehabil 2006, 85(7):559-67.

• Fozzatti MCM, Palma P, Herrmann V, Dambros M: Impacto da reeducação postural global no trataent a inc ntin ncia rin ria es r e inina ev ss c e ras li iene ipaviciene li as rasiene ects re ta ility ercises n ltifi s Muscles in Healthy Women and Women with Chronic Low-Back Pain. J Back Musculoskelet Rehabil.

2015;28(4):841-7.

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• Marques AP, Mendonca LLF, Cossermelli W: Muscular Stretching Exercises in Patients with Fibromyalgia from a Training of Postural Global Reeducation (PGR). Rev Bras Reumatol 1994, 34(5):232-4.

• Moreno MA, Catai AM, Teodori RM, Borges BL, Cesar Mde C, da Silva E: Effect of a Muscle Stretching Program Using the Global Postural Reeducation Method on Respiratory Muscle Strength and Thoracoabdominal Mobility of Sedentary Young Males. J Bras Pneumol 2007, 33(6):679-86.

• Moseley GL, Flor H. Targeting Cortical Representations in the Treatment of Chronic Pain: A Review.

Neurorehabilitation and Neural Repair. 4 ed. 2012 Feb 13;26(6):646–52.

• Neto J, Pastre CM, Monteiro HL: Postural Alterations in Male Brazilian Athletes who Have Participated in International Muscular Power Competitions. Rev Bras Med Esporte 2004, 10(3):199-201.

• Oliveri M1, Caltagirone C, Loriga R, Pompa MN, Versace V, Souchard P. Fast Increase of Motor Cortical Inhibition Following Postural Changes in Healthy Subjects. Neurosci Lett. 2012 Nov 14;530(1):7-11.

• Souchard P-E, Meli O, Sgamma D, Pillastrini P: Rieducazione posturale globale EMC (Elsevier Masson SAS, Paris), Medicina Riabilitativa, 26-061-A-15; 2009. c y ie la t iel n a Pyc a as e s i lec ech s a as Golec E. The Impact of Deep Muscle Training on the Quality of Posture and Breathing. J Mot Behav. 2017 Aug 18:1-9.

• Tavares A, Cabral R, Gomes D. P640 The Global Posture Reeducation (GPR) as a Novel Therapeutical Method for Stress Urinary Incontinence in Post-Menopausal Women. International Journal of Gynecology and Obstetrics. International Federation of Gynecology and Obstetrics; 2009 Oct 1;107(S2):S596–6.

• Vanti C, Generali A, Ferrari S, Nava T, Tosarelli D, Pillastrini P: Rééducation Posturale Globale in sc l s eletal iseases cientific vi ence an linical Practice e atis 59(3):192-201. il sc ar ri e ernan e artine epa pe n rin t y the elation between Playing Football and Muscle Shortening. Fisioterapia 2004, 26(6):340-8.

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GPR training is designed to enable the physical therapist to respond to each patient’s individual needs."

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INTERNATIONAL TRAINING IN Prof. Philippe E. Souchard GLOBAL POSTURAL REEDUCATION® GENERAL GOALS AND PURPOSES Training in Global Postural Reeducation (GPR) is intended for physical therapists or people with similar degrees. This system is designed to enable these professi nals t in ivi ali e their treat ent in r er t resp n t the specific nee s each patient. GPR is used to treat patients with neuromusculoskeletal alterations, primarily postural disorders and biomechanical symptom GENERAL PURPOSES To provide a pedagogical environment conducive to learning GPR with a focus on allowing professionals to acquire the expertise to: • Develop the knowledge and skills required to plan and form treatments for different desorders of the musculoskeletal system.

• Become autonomous, discerning professionals who can design strategies for managing needs on a case-by-case basis.

• Once they have completed all four levels of the training, students will be able t eval ate ia n se an plan treat ents in the fiel s rph l ical c rrection and symptomatic musculoskeletal disorders, and manage joint dysfunctions, from the GPR perspective.

GENERAL GOALS Once they have completed the training, students will be able to: • Apply clinical reasoning from the GPR perspective, for evaluation, diagnosis and treatment.

• Personalize their approaches on a case-by-case basis. se the ac ire s ills r the specific ane vers r p st ral c rrecti n t e applied in the treatments intended for the different neuromuscular and musculoskeletal systems.

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OVERVIEW OF RPG TRAINING There are four levels of RPG training, each of which incl es a five ay ace t ace sessi n h rs • Level 1 ana in rph l ical lterati ns the pine an ss ciate y pt s • Level 2 ana in int ys ncti ns the pine an ss ciate y pt s • Level 3 ana in rph l ical lterati ns the pper an er i s an ss ciate y pt s • Level 4 ana in Peripheral int Pain an ss cia te y pt s n a iti n t the r asic levels trainin speciali e c rses are availa le in specific a vance courses focusing on the treatment of: • Scoliosis.

• Craniocervical junction disorders through the oculo t r syste e r sens ry t r inte rati n e p r an i lar an cervical spine ys ncti n Palpat ry anat y

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Level 1 Managing Morphological Alterations of the Spine and Associated Symptoms Aims Secure professionals who can evaluate, diagnose, plan and develop treatments aimed at correcting postural alterations of the spine and the associated symptoms.

General goals Objectives Students will gain: • the conceptual and physiological reasoning behind GPR method.

• the theoretical knowledge hands-on training to conduct an evaluation • to plan an approach to the most common postural alterations that affect the spine.

• the theoretical and practical knowledge to provide treatment on a case-by-case basis.

Contents • Foundations and principles of GPR • Muscular physiology in postural organization • Treatments in GPR, general aspects • Breathing, its function in the diagnosis, and the treatment of breathing in GPR • Managing postural alterations of the spine • GPR evaluations • GPR treatment postures Level 2 Managing Joint Dysfunctions of the Spine and Associated Symptoms.

Managing joint dysfunctions of the spine and associated symptoms. Spinal joint dysfunctions.

Objectives Students will gain: • the contents of anatomy and biomechanics aimed at the analysis, diagnosis and treatment of spinal joint dysfunctions.

• knowledge on joint dysfunctions to be able to identify them during clinical practice.

• expertise on the clinical logic and evaluation required for a diagnosis • management strategies aimed at modifying spinal joint dysfunctions and the factors perpetuating them.

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Contents • Review the foundations and principles of the method developed in Level 1 • Conceptual framework and evaluation of dysfunctions of the spine • Joint biomechanics • Cervical joint dysfunctions • Thoracic joint dysfunctions • Lumbar and pelvic joint dysfunctions n ence the perine in pelvic ys ncti ns Level 3 Management of postural and functional alterations and associated symptoms of the upper and lower limbs.

Objectives Students will gain: • the theoretical knowledge and hands-on training to develop an evaluation and plan an approach to the most common postural alterations that affect the upper and lower limbs.

• the theoretical knowledge and hands-on training to provide treatment based on case-by-case needs.

Contents • Morphological alterations of the upper limbs • Morphological and postural alterations of the pectoral girdle and shoulder • Morphological and postural alterations of the elbow rph l ical an p st ral alterati ns the rist han an fin er • Evaluation and treatment of postural and functional alterations of the upper limbs • Morphological alterations of the lower limbs • Morphological and postural alterations of the pelvis and hip, and their relationship to the lumbar spine • Morphological alterations of the knee (genu varum, genu valgum, genu recurvatum, etc.)

• Morphological alterations of the foot (pes planus, pes cavus, pes valgus, etc.)

• Evaluation and treatment of postural and functional alterations of the lower limbs

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Students will be capable of conducting evaluations, reaching a diagnosis and planning treatments."

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Level 4 Management of joint dysfunctions of the upper and lower limbs and associated symptoms.

Peripheral joint dysfunctions.

Objectives Students will gain: • the contents of anatomy and biomechanics, aimed at the analysis, diagnosis and treatment of peripheral joint dysfunctions. n le e a t peripheral int ys ncti ns acilitatin their i entificati n rin clinical practice • expertise on the clinical logic and evaluation required for a diagnosis.

• management strategies aimed at modifying peripheral joint dysfunctions and the factors perpetuating them.

Contents Upper limbs 1. Joint dysfunctions of the pectoral girdle • Description of the dysfunctions a. Sternocostoclavicular joint b. Acromioclavicular joint c. Glenohumeral joint • Principles of evaluation and treatment of dysfunctions 18

2. Biomechanics of the elbow complex • Description of dysfunctions a. Proximal radioulnar joint b. Distal radioulnar joint • Principles of evaluation and treatment of dysfunctions 3. Biomechanics of the wrist and hand complex. Anatomical-biomechanical review of the joint complex of the wrist and the hand.

• Dysfunctions a. Radiocarpal joint b. Midcarpal joint c. Carpometacarpal joint d. Metacarpophalangeal joint of the thumb e. Metacarpophalangeal joints II to V. f. Interphalangeal joints • Principles of evaluation and treatment of dysfunctions Lower limbs 1. Joint dysfunctions of the hip a. Anterior hip glide b. Posterior hip glide • Interrelation with sacroiliac and lumbar dysfunctions • Principles of evaluation and treatment of dysfunctions 2. Joint dysfunctions in the knee complex • Joint dysfunctions a. Tibiofemoral joint Pr i al ti i fi lar int c. Patellofemoral joint d. Meniscal • Principles of evaluation and treatment of dysfunctions 3. Joint dysfunctions in the ankle and foot complex • Joint dysfunctions a. Talocrural joint d. Talocalcaneonavicular [WG4] joint n eri r ti i fi lar int e. Metatarsophalangeal joints c. Subtalar joint f. Interphalangeal joints

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