Dynamic Neuromuscular Stabilization (DNS)–Personal Musings and Clinical Perspectives

Dynamic Neuromuscular Stabilization (DNS)–Personal Musings and Clinical Perspectives
November 27, 2011 Dr. Phillip Snell

Theraband use for RNT in First Position of DNS

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.

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Dead Bug progressions video viewable by members of MyRehabExercise.com

Wall Bug progressions video viewable by members of MyRehabExercise.com

Baby Get Up progressions video viewable by members of MyRehabExercise.com

 

 

 

 

 

 

 

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Below, Ken Crenshaw, ATC, lead trainer for the Arizona Diamondbacks discusses the role of DNS in the management of pro baseball players.

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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.

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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.

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