This past weekend I had the pleasure to attend the Stuart McGill – Gray Cook Summit at Stanford University hosted by Dr. Craig Liebenson. I’ve allowed the information to gel for about a week as I considered how what I learned may affect my practice on a day-in and day-out basis. One of the most refreshing takeaways from the weekend was a sense of collaboration between the parties involved. What had all the potential of turning into a contentious weekend with various camps trying to defend their area of expertise, turned into a Kumbaya moment with all involved focused more on how we can combine our resources to help others rather than fighting amongst ourselves. Since I greatly respect both of these individuals and use their approaches in practice daily, I was excited to see that mutual respect on stage and in the break-outs.
A recap of the summit has already been well laid out by Dr. Bobby Maybee, Patrick Ward, Dave Draper and Dan John, so I wanted to focus this post on the clinical gleanings of the weekend. Let’s get solution oriented and try to build a better mousetrap shall we? I’ll start with the pros of the FMS that all of us in attendance seemed to agree on…
— establishes a numerical rating system and nomenclature that allows better communication between rehab and performance professionals. To my mind, this is somewhat analogous to getting a drivers license and learning to read road signs.
My personal feeling is that if we stop right there and the FMS never does anything else…then it has provided an invaluable service with those things above. Let’s don’t put it out to pasture quite yet though, huh? Let’s talk about what needs improvement…
Common errors by novice users of the FMS were discussed by both Gray Cook and Stuart McGill and they both agreed that these result in problems with the FMS in general. If you’re guilty of these errors, stop! You’re making the FMS look bad!
1. Training decisions based on the summed total of the screen rather than attacking low values and asymmetries.
2. Assuming that the presence of 0’s, 1’s or low summed total score does not mean the client can’t train, you just have to be smart about how you do it. It also means you need to know if you’re smart or not. 🙂
3. Many novice users perceive that an adequate score on the FMS is sufficient information to load volume and intensity without further assessment.
These issues represent poor use of a good tool so better education and chats like this can help to improve that, hopefully. Now let’s discuss some of the places where the chassis the FMS is built on might need some work.
Current shortfalls of the FMS were discussed at Stanford and the concerns that came up were…
1. It does not predict injury as well as hoped. Some subgroups it works okay in, but in the general population not so well.
2. It does not account for lumbar hinging, i.e. loss of lumbar lordosis with movement.
3. It still does not account for lumbar hinging. (See what I did there?)
4. A good score on basic movement does not necessarily mean that that movement quality will transfer to daily tasks.
Dr. McGill consistently brought evidence to the table to suggest that if we are to assess injury risk then these specifics need to be accounted for:
1. Understand the biomechanical challenges, loads, and exposure variables associated with a particular task or sport.
2. Understand the available literature associated with the common injuries associated with that specific sport or task.
3. Apply specific coaching techniques to avoid potentially provocative positions, loading strategies, and exposure variables.
He showed studies he’s done (in preparation for press) that show that you can score a 3 on an overhead squat on the FMS and then still show crappy form picking up a coin from the floor and with other daily squatting and lifting movements.
So coaching of movement quality is a good idea that evidence suggests can prevent injury? I like it! So what does that look like? The demo session in the afternoon at the summit provided a glimpse.
A volunteer from the audience, Will Nassif, was 1st screened using FMS on stage by Dr. Kyle Kiesel and Dr. Mark Cheng. Will received a score of 15 with no zeros or ones. Of note, he scored a 3 on the squat test.
Subsequently, Dr. McGill attempted to demonstrate some of the specific tasks that he recently applied to a firefighter community. One of those tasks included a loaded rope pull, hand-over-hand. In positioning Will in a good neutral spine, braced position, Dr. McGill noted an antalgic positioning in Will’s lower back as he placed his hand on the lumbar spine to palpate his movement quality in that area on set up. At this point he asked will if he had previously had a disc injury. It was revealed that he had and that he had been rehabbing it (BTW, Will gave permission for this public revelation of his status).
In the set up for the hand-over-hand rope pull, Dr. McGill repeatedly positioned and coached Will through the movement to preserve a neutral spine throughout. As an aside here, I have to take issue with my friend Patrick Ward’s ending note in his excellent recap of the weekend when he stated that McGill’s approach to movement screening is to “put the person under load and see what happens.” From my experience with Dr. McGill over the years, I can say that his history, movement assessment and manual exam are exhaustive. As Stu pointed out, this process takes about 3 hours. Patrick and I chatted about this over pints and agreed that the overall process we observed on stage was what we should all doing in good practice. Do a general movement screen to see if the person can tolerate an unloaded challenge and then observe how the controlled loading affects the system. What Stu took care to do was to assess the integrity of Will’s L-spine position prior to loading.
This pointed out the biggest thing that some of us see as a problem with the current FMS. There is no screen for quality of the movement about the lumbar spine. Some might argue that that info comes out in the hurdle step or the leg raise and I might agree, but when the picture below is presented as a 3 (by definition, movement that is exemplary and can’t be improved on) then some trainer is going to assume that that gives them license to load that back in that position.
That back in that position might get by with that movement for a while but will likely fail in that spinal hinge sooner or later. To my mind, for durability, how you achieve the movement is more important than whether you can perform the movement. Could this gent get to that depth with a lumbar lordosis with corrective exercise? Possibly. But he may also have anatomical limitations that prevent that, like the s0-called “Scottish hip” that Stu has pointed out in the past. At Stanford, he once again brought this up in assessment of a couple of hips, pointing out that sometimes you might just need to avoid ATG squatting due to anatomy. Bottom line, squatting deeply has a point of diminishing returns past the point where you can maintain lordotic curve in the L-spine.
Below you can see what the genes and the training combined will allow in a world champion Oly lifter. My simplest recommendation would be make the 3 for the OH Squat look like Jerzy Gregorek’s below, with a well-preserved L-spine lordosis in the hole. All else is a 2 or less.
So what are we left with from the weekend? The way I see it:
- It seems that we need to stop short of using the FMS as a prediction tool for future injury unless further studies define subgroups with which it’s more effective.
- Summed scores don’t offer much info unless below 14, and that might have a ± variance of 2.
- 0’s still warrant referral for clinical eval.
- Don’t assume that a >14 score and no 0’s or 1’s on the FMS gives a green light to load a pattern without further specific assessment. It would be great if I came up with that idea, but Gray actually did in Athletic Body in Balance some time ago.
In closing, special thanks to Craig Liebenson for organizing this party and to Gray and Stu for the time and courage to pull it off and to Laree Draper for archiving it. Now let’s get our there and help some folks!
A recent paper from the Mayo Clinic in Rochester, MN (Yuan et al, 2013) appeared in the American Journal of Sports Medicine which brought to light that screening the hip range of motion (ROM) in young athletes might be worthwhile to identify problems that might be in that athlete’s future. Yuan, et al found that a simple modified flexion/adduction/internal rotation (FADIR) impingement test in asymptomatic athletes was able to pick up early stages of cam type of femoracetabular impingement (FAI). Specifically, they assessed 226 athletes for internal rotation deficits by flexing the supine athlete’s hip to 90 degrees, and then applying adduction and internal rotation. They also received the impingement test which was essentially the same test with hip flexion performed to endrange. 19 of those athletes (8%) demonstrated IR <10 degrees and 34 of 38 hips in those athletes demonstrated <10 degrees IR-ROM. Only 18 of those hips had pain with the impingement test. Of those with positive findings, 13 chose to participate in the study. A control group of 13 was chosen from normals from the the original N=226 cohort and both groups received Xray, MRI, and a subsequent manual exam.Significant findings included:
The final paragraph is excerpted below, which asks some important questions we need to answer in future studies:“As more information about the natural history of FAI becomes available, it will be important to understand how and why the pathoanatomy of FAI leads to future hip injuries in some patients. Specifically, if there is a way to easily screen for those with reduced hip clearance, does counseling those patients on avoiding activities that require forced hip motion to the extreme reduce the development of symptomatic FAI or even OA in the future? Currently, we do not recommend any sports-related or activity modification based on the results of a ‘‘positive’’ screening examination result. This study, however, provides new data that can be used to compare future longitudinal natural history studies. Obviously, the data on the natural history of FAI are necessary before definitive recommendations regarding activity modification for the adolescent athlete can be made, such as avoiding ballet or playing as a goalie in hockey. Additionally, there is probably a little role for prophylactic surgery. However, our findings suggest that a simple hip examination may have utility as a screening test in asymptomatic patients to detect the hip at risk of future pathological changes secondary to impingement during high-risk activities.”A few other questions came up for me in my review of this material. I’ve included those questions and links for those that are interested in chasing this out a bit further.1. How do post surgical FAI hips fare in kids, adolescents and adults?-(Philippon 2008, Philippon 2009) Pretty good…if you ask a surgeon.2. What’s the current thinking on most effective clinical exam for the hip? (Martin et al, 2006) A test cluster is suggested but has not yet been thoroughly researched.3. What are the methods of assessing the alpha angle in the hip?From Taunton on OrthopedicsOne reference site, on AP Xray or MRI, “the alpha angle is formed by a line drawn from the center of the femoral head through the center of the femoral neck, and a line from the center of the femoral head to the femoral head/neck junction, found by the point by which the femoral neck diverges from a circle drawn around the femoral head. At present, the upper end of normal is an alpha angle of 50 – 55 degrees.” Serbian researchers (Andjelkovic, 2013) recently described a newer method of radiographically assessing the alpha angle on plain film.4. What other studies implicate the alpha angle in hip pathology? (Beaule, 2012) Makes one wonder if heavy back squats and ATG cueing in those squats is a good idea in adolescents.5. If high alpha angle indicates structural predisposition to hip pathology, what exercise and/or rehab can we suggest for our patients?I really like the combo of DNS-influenced exercise progressions that Jeff Cubos, DC put together on his blog.In closing, several studies have suggested that in young populations, the presence of FAI in young active patients is likely to lead to significant osteoarthritis in later years.(Ganz, 2003; Tanzer, 2004; Wegner, 2004) In older populations the jury is still out. Hartofilakidis et al in 2011 performed a retrospective study and tracked 96 asymptomatic, middle-aged hips with radiological evidence of FAI and found “…that a substantial proportion of hips with femoroacetabular impingement may not develop osteoarthritis in the long-term. Accordingly, in the absence of symptoms, prophylactic surgical treatment is not warranted.”References:
- Mean alpha angle on MRI was 44.3 in the control group and 58.1 in the study group.
- 86% of those asymptomatic hips with clinical signs in the study group demonstrated abnormal findings on plain film Xray.
- >2/3 of the study group had MRI demonstrated pathology vs. 1/3 of the study group. The more accurate MRA assessment was not ok’d by IRB for pediatric population.
Yuan BJ, Bartelt RB, Levy BA, Bond JR, Trousdale RT, Sierra RJ. Decreased Range of Motion Is Associated With Structural Hip Deformity in Asymptomatic Adolescent Athletes. Am J Sports Med. 2013 May 22.
Philippon MJ, Yen YM, Briggs KK, Kuppersmith DA, Maxwell RB. Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient: a preliminary report. J Pediatr Orthop. 2008 Oct-Nov;28(7):705-10.
Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up. J Bone Joint Surg Br. 2009 Jan;91(1):16-23.
Andjelković Z, Mladenović D. Measuring the osteochondral connection of the femoral head and neck in patients with impingement femoroacetabular by determining the angle of 2alpha in lateral and anteroposterior hip radiographic images. Vojnosanit Pregl. 2013 Mar;70(3):259-66.Tanzer M, Noiseux N. Osseous abnormalities and early osteoarthritis: the role of hip impingement. Clin Orthop Relat Res. 2004;429:170- 177Wenger DE, Kendell KR, Miner MR, Trousdale RT. Acetabular labral tears rarely occur in the absence of bony abnormalities. Clin Orthop Relat Res. 2004;426:145-150.Beaulé PE, Hynes K, Parker G, Kemp KA. Can the alpha angle assessment of cam impingement predict acetabular cartilage delamination? Clin Orthop Relat Res. 2012 Dec;470(12):3361-7.
Hartofilakidis G, Bardakos NV, Babis GC, Georgiades G. An examination of the association between different morphotypes of femoroacetabular impingement in asymptomatic subjects and the development of osteoarthritis of the hip. J Bone Joint Surg Br. 2011 May;93(5):580-6.
On Jan 10-13 I had the pleasure of attending the DNS-Sport 1&2 courses in LA at Chris Powers’ Movement Performance Institute and given that many have contacted me about the content of the course, thought I should put together a review. My exposure to DNS to date has been through the clinical track of DNS A,B and C certifications (C cert pending) over the past 3 years and may continue with D level in the next year.
I will say that I entered this Sport course with some reticence as I was not sure whether adding more DNS material in my toolbox was going to help much. The primary tools I was looking for, corrective exercises to share with patients, seemed to be an afterthought in my previous courses. My specific points that I was personally concerned about with my prior DNS classes were:
- Too much focus on internal cueing strategies vs external cueing strategies
- Too little focus on corrective exercises to share with patients to reduce need for care
- Prevalence of so-called Vojta ‘reflex stimulation points’ in the course matter
- Poor organization of material and course notes
- Too much focus on pediatrics
So How Were the DNS “Sport” Courses Different?
I was stoked to find that the “Sport” courses had left out pediatrics, reflex locomotion material and internal cueing focus had been de-emphasized! Finally too, exercise strategies we can share with our patients and clients were the focus! I was very excited about this turn of direction in the DNS course work but heard from some of my strength and conditioning (S&C) colleagues that they were concerned about the persistent clinical focus of the course and the hands-on cueing demonstrated. Grand Rounds focused on injured athletes, but instructor Petra Valouchova studiously avoided rendering a diagnosis or focusing on tissue injury. Instead the focus was on movement assessment and correction, these are tenets that are the bailiwick of both the S&C world and in the clinical rehab world thanks to the FMS/SFMA paradigm shift provided by Gray Cook. Statutes and scope of practice restrictions in much of the world prevent trainers and S&C folks from manual contact with their clients, but the roughly 50% population of S&C folks in the room, they saw that this material was easily verbalized to potential clients.
When I came back home to Portland, the only regret I had was that the incredible group of S&C folks that I share patients and clients with did not yet have this material under their belts. While the FMS/SFMA palette gives clinicians and trainers a common language to speak and hand off to each other with, the DNS material has not reached that level of common usage yet. The courses I attended provide that common map from which we can use our respective fields of experience to orienteer.
What’s in a Name?
I think that perhaps the “Sport” designation was a misnomer that grew out of earlier conversations about how to create a template that clinicians and trainers can work from together. I propose that these “Sport” courses are a MUCH better introduction to motor pattern ontogeny and to achievement of proper joint centration to set the stage for performance than are the clinical A, B, C, D level courses. As a result, I think the current Sport courses should carry a name that better reflects their content…something like
- DNS 1-Introduction of Developmental Motor Patterns,
- DNS 2-Application of Functional Joint Centration to Reduce Injury.
- The true “Sport” course, which has yet to be developed, would focus on use of these principles to bring optimal performance to athletics. I’m thinking of a name like DNS 3-Optimizing Performance with DNS Principles. Those venues would be in gyms and weightrooms and Grand Rounds would not be injured athletes, but would instead feature promising athletes at different developmental levels who want to run faster, jump higher, throw farther. I could see those courses using items like Omegawave over subsequent days and OptiGait and slow motion video capture to see pre and post DNS interventions in the healthy athlete. Further coursework could focus on sport specifics…Track and field, Cycling, Tennis, etc. See..now I’m excited!
DNS Sport At Present
For now, the course content of the DNS-Sport classes is as follow:
DNS Sport 1 and 2 are an introduction to ontogenic motor patterns.
Course 1-Focuses on development of deep spine stabilization system via diaphragm/pelvic floor and TA
Course 2-Focuses on joint centration of limbs on the deep spine stabe system. Course 2 also teaches assessment and correction of common motor pattern faults that can lead to injury. Here I’m talking about the chronically tight hip flexors and traps that defy daily stretching techniques. We all see these in clinical practice and might even know them as Upper Cross and Lower Cross through the Janda perspective. However, many of us with manual toolboxes ‘face palm’ daily about the recurrent tightness in those muscles that doesn’t respond to stretching, ART, Graston, foam rolling, lacrosse balls, etc. DNS offers a window to effectively treating these hypertonic muscles by improving intrinsic spine stabilization to take to adaptive stabilization roles these types of muscles off of the table. Phasic muscles return to their movement roles and very quickly decrease hypertonicity when the stabe system is returned.
So, should you, as a trainer or clinician, cough up the $$ to bring this understanding to your patient/client population? IMHO, the answer is an enthusiastic YES!!! Moreover, I think the current DNS-Sport 1&2 courses embody best way to gain access to this material in an organized, well-presented manner…even if the courses are named wrong 😉 In the future, that Performance course I wished for above , will be presented and you will want to have the understanding represented in the current Sport courses. If you want opinions of others that attended the Sport courses, check out the videos below.
Finally for my colleagues in Prague, I would also offer constructive criticism that the courses would be improved by offering a repository of videos to course attendees which offer review of the movement patterns. Perhaps the excellent library that Mike Rintala, DC and Dave Sabo are cranking out can be used! I can imagine a password protected site where attendees could see instructors demonstrating and covering the essential points of prone and supine movements on video for their own review. I could also see benefit in another service for attendees consisting of PDFs of specific exercises that are covered in these courses. These PDFs could contain photos and key points and work as handouts to help the patients and clients do their home exercises. Just a thought!
I’m still rolling with the excellent presentations I was witness to in Seattle at the Perform Better 1 Day Event on April 21, 2012!! Sadly, when I searched my calendar for the upcoming 3-Day evenets I found that I was already booked on the dates of the Providence, Chicago and Long Beach summits. What are the odds!? The rest of you should be at one of those though. Here is my take on the event that weekend that featured some real heavy hitters…
As fate would have it, Mike Boyle who was on the agenda, was tied up with spring training in his new job with the Red Sox. While I was disappointed to not meet Mike, the guy who pinch hit for him wasn’t half bad either! Gray Cook stepped in to join Charlie Weingroff, Rachel and Alwyn Cosgrove for one of the most enjoyable, well organized and knowledge filled continuing ed events I’ve attended in many years. The format was an hour of didactic from each presenter, lunch, and then the afternoon was 30-40 minutes rotating between 4 hands-on stations hosted by each presenter. In contrast to the typical neck and back numbing sit-fest that usually is present in a weekend CEU event, this one even managed to allow participants to get a bit of a workout in.
Rachel led off with an excellent presentation that chronicled her work with training over the years and her eventual focus on training women and fat loss clients. Participants got a good dose of the psychology that is inherent in managing these clients and keeping them motivated for results. In the afternoon, she led attendees through thoughtful exercise progressions from corrective to high performance and did a masterful job matching the training strategies to FMS scores on the FMS screen. I appreciated the low tech/low space approach of using kettlebells, furniture sliders, resistance bands and TRX suspension trainers to go through some very creative approaches to managing some challenging functional limitations. Keep your eye out for these correctives in the member’s area for MyRehabExercise.com in the future!
Charlie is perhaps the only guy on the speaking circuit who can address 200 people in an 8000 square foot hall without really needing a mic! He brought his obvious passion to breaking down some of the DNS material into the training environment with Understanding Joint Centration. He continually brought the listeners around to the feedforward process of centering of joints to allow for green light from the cortex for optimal and painfree performance. In the afternoon, he navigated that territory using TGU positions, allowing us to feel the difference in loading capacity in centrated vs. un-centrated positions. The sled pulls were especially entertaining in seeing the impact of pulling both with and without shoulder and neck packed positions with several volunteers really getting an excellent take home lesson! 🙂 I particularly liked the simple, elegant demo of toe touching with and without the neck packing. It went like this…
Position yourself with your back to the wall and a foot or so away from the wall. Pack the neck by performing a chin retraction and keeping the neck in neutral, i.e. don’t tip your head down. Bend forward and touch the toes, and wiggle your feet to position yourself where you are simultaneously touching the toes while barely touching your butt to the wall. Return to upright postion and repeat but this time arch your neck up and look at the ceiling. Put your butt against the wall and then try to touch the toes again. Can you feel how much more restricted your toe touch is? Imagine the implications as you try to deadlift and reduce your ability to toe touch. In our challenged patients and clients, this could result in a rounding of the lumbar spine as they try to get to the bar!
Gray was his usual entertaining self as he doled out detail after detail from his voracious reading habit. He made a case for the need for a checklist in our approach to assessment and a standardized system such as the FMS so that we can track changes in our patients and clients.I appreciated the sharing of Ed Thomas’s slides showing the evidence of dysfunctional movement in Americans in the 1950’s whereas 50 years prior movement pattern trends in physical education were much better. The example of the military rifleman shooting from a deep squat position in the 40’s and the need to change that training as the recruits showing up for training in later years steadily lost the ability to deeply squat.
Gray is also a thoroughly quotable figure. Below are a few of the gems that issued forth over the weekend:
Later in the break out session, the bear crawl races were good sport and we all got a chance to put the FMS to a quick application to split up into the motor integration challenged group and the mobility challenged group. Correctives for these were eye-opening with some coming from the Kettlebells From the Ground Up DVD. I rushed over to buy my copy but alas the last one sold just as I arrived 🙁 . One of those demoed was the Brettzel 2.0 which you can see below.
- ”You will not hear me tell a pt to engage the glutes. I’ll put them in a position where they can’t engage their quads and back and ask them to move.”
- ”We teach squatting in reverse in the gym…by putting the weight up high and move under it. Babies start on the ground and move their own weight up.”
- “People are not a bag of parts, they’re a bag of patterns”
- “That functional movement pattern your client/patient is looking for is not missing, it’s on their hard drive, but they’re having difficulty locating it.”
- “We’re all in the wrong business because the mark up on duck calls is like 7000%.” (Author’s note: OK, OK, this was later over dinner after enjoying the local ‘cider’)
Alwyn was very entertaining too but as a clinician, I must admit I was not excited for his talk on Cutting Edge Fitness Business Principles. However, I wound up taking a single pearl home that I think may ultimately be an excellent adjunct to the FixYourOwnBack site that I’m currently re-tooling. More on that later… Honestly, Alwyn’s gym, Results Fitness offers a fabulous training model for group training environment which captures a lot of the fun energy people seem to like in the Crossfit model, but offering sustainable movement exercise that challenges multiple energy systems while focusing on complex functional movements.
Later, he put us through a challenging 27 minute workout that hit all the basic high points: static mobility, dynamic mobility, strength, speed, power, reaction time and agility along with a nice metabolic challenge as a cherry on the top! Nice way to end the day! You can see an example of the gym flow at Results Fitness at this video below.
As it turned out, the day wasn’t over for me, and I had the opportunity to join Charlie, Gray, and Tim Vagen for dinner. As Charlie was co-presenting the following day nearby at Joel Jamieson’s gym along with Patrick Ward, those 2 joined us along with Sounders strength coach David Tenney. Rumours on the grapevine suggest that that event was recorded and will show up as a DVD in the near future so keep your eyes out! Great meal, great company and a fabulous event. I can’t thank the Perform Better folks too much for putting together a great event, and heartily encourage readers to get out to one of these gatherings in the near future. For a schedule of upcoming Perform Better events, click here!
As I write this from 30,000 feet on my way home from a recent course in Dynamic Neuromuscular Stabilization (DNS), I hope to provide some personal perspective and something of an overview of Pavel Kolar’s program with this post. My understanding is based on my experience of only 2 courses over the past 2 years, but I hope that it might offer a bit of help to those clinicians, trainers and bodyworkers who are considering ponying up the time, money and commitment to immersing themselves in this physical medicine approach. Below, you can also check out some other perspectives from folks that have been doing this a bit longer. At the end of the post you can find videos from Ken Crenshaw, ATC of the Arizona Diamondbacks; Sue Falsone, PT of the LA Dodgers and Drs. Mike Rintala and Brett Lemire who have been using the DNS approach at the highest levels of pro and amateur sports.
“As to methods there may be a million and then some, but principles are few. The man who grasps principles can successfully select his own methods. The man who tries methods, ignoring principles, is sure to have trouble.” -Ralph Waldo Emerson
The DNS approach is principle-focused, and thus allows for jazz-like riffs in the assessment and treatment of patients and clients. However, a solid understanding of the basics of human movement and assessment is a prerequisite to the course, and many will find that this material is like a post-grad diplomate for the FMS/SFMA protocols. For the official specs on DNS, check out the excellent Powerpoint presentations at the DNS website, www.RehabPS.com. The following are my own gleanings and represent the ‘bullet points’ that really stuck out for me after the 4 day course.
Principle 1- Proper orientation and function of the diaphragm is key to elegant movement.
Principle 2- In a healthy, developing central nervous system (CNS), proper diaphragm orientation and function are innate.
Principle 3- In a healthy, developing CNS, acquisition of motor programs occurs in a predictable, observable manner in the infant.
Principle 4- In adults, poor musculoskeletal function often starts when diaphragmatic breathing and stabilization is lost.
Principle 5- Improved musculoskeletal function can be re-acquired by returning to developmental stages of movement and re-grooving balanced movement in the presence of proper diaphragmatic breathing and stabilization.
DNS uses the clinical audit process (CAP) in application. In these methods, the patient is first assessed, a treatment is applied and the effect is then reassessed to determine short term effect of treatment. Studies have shown that long term prognosis in musculoskeletal conditions improves by 3 fold when within treatment benefit is noted. Much of the DNS assessment is on breathing patterns and postural stabilization using the diaphragm. Those breathing patterns are corrected by the clinician, often in positions that mimic developmental infant postures and movements. This process was built on the work of former Prague School of Rehabilitation head, Vaclav Vojta.
Vojta’s work with children suffering from cerebral palsy (CP) showed improvement in function of CP kids when this type of developmental approach was used. This is where one of the more controversial aspects of DNS starts to enter the picture. Vojta theorized that during development of motor programs, the infant’s observed progression from supine to sidelying to prone to sitting to kneeling to more advanced vertical postures resulted in areas of high sensory input corresponding to the weightbearing structures during that period of development. Vojta felt that these high sensory areas persist into adulthood and he coined the term ‘reflex points’ to describe them. In the adult, these areas of the body, like the anterior lower ribs, ASIS, medial knee and elbow, palm and medial calcaneus, theorietically can be used to access more primitive movement stereotypes that are innate to the human. Manual pressure to these points, again, theoretically, can ‘re-boot’ the more balanced respiratory and stabilization functions of the diaphragm and motor system, allowing for a better cache memory of movement that is balanced. Building on that temporary improvement with personalized exercise is the next step to restoring function to the musculoskeletal system.
In my own opinion, the evidence for these reflex points and reflex locomotion is tenuous at best. I’m happy to see that the DNS approach, while informed by the possibility of these special points, does not rely on them for application. In the training of the reflex points in the course, students are taught what anticipated movements might occur with stimulation of reflex points, and then they practice on each other. As a result, these “reflex movements” are highly suggestible, and I suspect that much of what is observed in the seminar environs is not truly reflex, but the wishes of the participants to experience the phenomenon. I have only the reports of trusted colleagues that this reflex movement occurs in a predictable manner in the naive patient. I very much try to educate patients about the origins of their dysfunction so that they are empowered to help themselves without need for treatment. Quietly waiting over a patient, while pressing specific reflex points, without telling the patient what you’re doing and why seems awkward to me. Telling them, however, removes the naivete. The real ‘magic’ IMHO, is in the anticipated movement patterns.
To my mind, the beauty of the DNS approach is in refining our understanding of ideal, anticipated movement patterns that occur with basic human movement stereotypes like rolling over, squatting, kneeling, stepping, etc. When adequate deep stabilization of the spine occurs, these pure movement patterns occur spontaneously in the infant. If spine stabilization is hampered in development or later in life in the adult, then aberrant motor programs become ingrained. These aberrant patterns of movement result in joint de-centration, with resultant negative effects on the joints, attached soft tissues and performance. Overuse syndromes, pain and suboptimal performance of movement in athletics are the results. The good news…Kolar has shown us how to intervene clinically by teaching the patient/client how to better stabilize the spine and then re-groove the ideal movement stereotype.
The clinician or trainer leads the patient into the ideal movement and weightbearing, and then can reinforce proper movement using reactive neuromuscular training (RNT) strategies. The challenge is in finding exactly when in the movement pattern that the individual loses stabilization, de-centrates and thus needs help. Practitioners require a refined ability to assess the nuances of movement quality. Prescribed DNS exercises are highly individualized to the patient/client, and rely heavily on internal cuing. That is, the patient/client is taught to feel the loss of integrity in the movement, correct it by stabilizing better and then continuing the movement with different weightbearing and force vectors that mimic the developmental movement stereotypes.
To those who are fond of algorithms and ‘low cortical output’ (read mindless) practice, DNS will disappoint you. This is a systems approach to the human body and requires you to be ‘on’ to apply it effectively. Like much of the modern functional approach in physical medicine, initial focus is on an individual assessment of the patient/client. This assessment frequently starts with territory that has for many of us been considered to be ancillary at best. DNS places great emphasis on the diaphragm and its role in not only respiration but also on stabilization of the core to create a fixed point (punctum fixum) for the hips and shoulders to plug into to generate movement.
I have already seen benefit using these methods on those patients (including myself) that I have not quite been able to rehab completely using the other paradigms like FMS/SFMA, McKenzie, McGill, etc. My next personal challenge will be in how to represent this material well in the exercise roster at MyRehabExercise.com to help clinicians and trainers more easily teach these strategies to their patients and clients. So far, the DNS approach has been tangentially represented at MyRehabExercise in some of the Dead Bug exercise progressions, Baby Get Up from Craig Liebenson, DC and perhaps even in the Turkish get up break downs in the rehab setting. Look for more refinement of the exercises on MyRehabExercise in the future to include more detailed DNS based methods.
Membership to MyRehabExercise.com is only $9.99 per month and allows access to an extensive library of functional rehab exercise video tutorials to help with patient and client rehab exercise training. Trial the site for only $1 for 30 days with no obligation.
Below, Ken Crenshaw, ATC, lead trainer for the Arizona Diamondbacks discusses the role of DNS in the management of pro baseball players.
Sue Falsone, PT is the first female head of athletic training in any of the 4 major league sports in the US. She was recently hired by the LA Dodgers to help oversee the care of those players. Here, she discusses the role of DNS in the athletes she helps to treat in her work as head PT for Athlete’s Performance International.
Dr. Mike Rintala and Dr. Brett Lemire were ‘early adopters’ of the DNS program and incorporated it into clinical practice starting 10 years ago. Dr. Rintala discusses the effect of DNS in working with pro and amateur athletes including PGA Tour pros. Dr. Lemire discusses the effect of DNS in a standard DC practice.
Happy Thanksgiving all! Here in the US, today is a holiday set aside to gather with family and reflect on the things that we have to be thankful for. I feel truly thankful this year for not only my own family, but also for the professional family that I’ve been fortunate enough to be adopted into this past year. I want to thank you folks for playing together on Facebook and in the blogosphere and especially for spending time together at continuing education weekends. This past few weeks have been quite active in that regard with back-to-back long weekends on a cranial download of Fasical Manipulation and Dynamic Neuromuscular Stabilization (DNS) coursework.
For those who haven’t yet been exposed to the DNS material, it is the latest in the evolution of the Prague School of Physical Medicine and is the brainchild of Professor Pavel Kolar. Dr. Kolar is the current head of the school which is housed at the Motol University Hospital in Prague, Czech Republic. Past heads of the school have included Vaclav Vojta, Karel Lewitt, and Vlad Janda. Kolar’s work has been greatly influenced by Vojta’s work with children with cerebral palsy (CP) which started back in the 1950’s. Vojta’s observed that the innate developmental movement patterns of infants are not only predictable in their ontogeny, but that those predictable patterns are disturbed at a very early age in CP kids. To an astute observer, those flawed patterns offer an opportunity to diagnose CP at an earlier age, and then to intervene for those kids’ benefit. Vojta found that grooving more normal motor programs in those children helped them achieve higher levels of function.
Pavel Kolar’s work was also informed by his athletic experience as an Olympic gymnast for the Czech Republic. Kolar wondered whether children with CP might not be the only benefactors of Vojta’s ideas. He began to note that the commonly presenting pain syndromes in adults were coupled to poor movement patterns that mirrored the faulty movement patterns observed in CP kids. When he began to apply the same exercise strategies in these adults, their pain syndromes improved. Given his athletic background, Kolar started applying the DNS principles with athletes for performance improvement and once again found success. Today, high performance athletes are beating a path to Prague and to those practitioners worldwide who are well versed in these techniques.
This past weekend, one of the larger courses in the US was held at Athlete’s Performance International in Phoenix, AZ and included classes in the A, B, C and Advanced levels of training. The roughly 80 total participants were treated to grand rounds with professional athletes and world record holders. The attendees included physical therapists, chiropractors, MDs, athletic trainers, personal trainers and bodyworkers. One of the most satisfying aspects of this DNS community is the ‘cross-pollination’ between the healthcare disciplines that occurs at these events. I was privileged to be able to interview a few of the instructors and attendees before I left Phoenix and those interviews will be posted in this and the next entry here. To learn more about the DNS program, go to www.RehabPS.com and register for their limited seating courses to be on the cutting edge of the new Rehab Renaissance.
Alena Kobesova, MD is a familiar face to US DNS attendees as she works as a lead instructor for the Prague School, but also functions eloquently as Pavel Kolar’s translator. Here, Dr. Kobesova speaks about the DNS perspective on the diaphragm’s role in respiration and stabilization.
Dr. Craig Liebenson has played a pivotal role in the last 20 years in gaining a US audience for the work of the Prague School. He has hosted Vladimir Janda and Dr. Kolar many times, and was the main organizer for this event in Phoenix at API. Here he discusses open chain vs. closed chain exercises in the DNS program.
Clare Frank, DPT is one of the primary DNS instructors in the US programs and was co-author of Assessment and Treatment of Muscle Imbalances: the Janda Approach. Here she discusses the misconceptions of many about the importance of reflex points and reflex locomotion in the DNS system and also explains the influence of Janda’s work on the DNS point of view.