A recent inquiry from a friend and colleague whom I respect VERY highly.

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“Where does DNS or the SFMA stuff fit into the new approach you have to therapy based on what you learned from the Mosely course? Or, are you using it but explaining things differently?”

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I definitely am still using DNS and the SFMA. And I think it all fits in nicely. To give you a better appreciation, here’s my typical framework, which I think you’ll probably resonate very well with.
In my opinion, the clinical history is paramount. Here we can identify where the “condition” falls in the continuum between acute and chronic. Perhaps more importantly, the more astute clinician will be able to identify the goals of the patient, their thought process, their tendencies, their activity levels and behaviours, their coping strategies and ultimately, their understanding of their condition as well as the pain they are experiencing. While I’m listening, I’m paying attention to (amongst other things) their body language, they’re level of anxiety (if present), and their ability to make eye contact.
From the above, I’ll classify their presentation and formulate the most appropriate assessment and treatment strategy. And I’ll always use the most appropriate dialogue and communication strategy based on what I find. If I feel they need more reassurance, they’ll get it. If they need more gentle verbiage, I’ll provide it. If they simply need to understand their injury, they’ll get the explanation. If they need a kick in the you know what, then I’ll give it to them. Rarely will the above and other communication strategies be in isolation. Typically it is a take a little from here and there, buffet-style, approach.
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For acute traumatic presentations:
  • I’ll utilize an orthopaedic based assessment to identify the tissue injured and modulate their symptoms accordingly. Somewhere along the way, whether initially or down the road, I’ll utilize a functional approach (likely the SFMA – though sometimes modified, if I feel I need to take an early exit) to identify how I can spare the tissue.
For acute non-traumatic presentations:
  • I’ll start with the SFMA and put the cherry on top with the appropriate orthopaedic tests. For example, in a recent discogenic case that wasn’t clear cut, the SFMA got me there. A DN MSF led me to the SLR tests which were positive, then confirmed with the other disc tests. Treated with a McKenzie style approach but the patient definitely had fundamental core stability deficiencies so low tech strategies were used. I believe I used DNS’ reflexive stimulation alongside McGill and Cook based stability exercises (though rolling was omitted) as well to spare the spine.
For the subacute and chronic presentations:
  • I generally go straight to the SFMA. Again, I’ll exit this highway and break the rules if I feel confident that a better strategy is necessary but I generally start with the SFMA. In chronic presentations, my communication skills become paramount and I definitely pull out the teaching/educator hat. I’ll pull out whatever resource I have (e.g. “Explain Pain”) to ensure that they walk away with a better understanding of their painful experience. I have found that many patients presenting with some form of chronic pain, regardless of whether they are an athlete or not, and especially if it “has to do with the low back or neck”, will demonstrate breathing deficiencies so I will attack this route in my plan of management. Sometimes they need the witchcraft associated with DNS and other times the breathing switch turns on like butter. But I do feel that many patients can benefit from a hands on approach. If I strictly utilized the education/explanation approach, they’ll think I’m a psychologist and may even walk away with the impression that I think they’re crazy or its all in their head. We all are aware of the power of touch and since I generally place movement quality at (or near) the top of my priority list, then I’ll go after it. That’s pretty much why I use the SFMA. However, the SFMA will often lead me to a fundamental stability issue of which this takes me back full circle to breathing. But I will also respect the work of the Prague group and attempt to facilitate the external rotators, abductors, and extensors as well. Not so much in an isolative manner but more so in an integrated, subcortical, motor learning, neuroplasticity fashion that does incorporate breathing. If it leads me to a mobility issue, then I attack that.
For additional therapy, I’ve been more keen on incorporating kinesiology tape with a neurosensory approach, as well as gentle touch and vibration. Based on Moseley and the pain science folk, during treatment I may have them cross their arms, I may use mirror imagery, and I may try to facilitate improved sensory discrimination (i.e. two point discrimination – “close your eyes and tell me if my contact on your skin is with one finger or two”). Though this is more likely to be included in the chronic cases. I think these approaches tap into specific areas of the brain (i.e. premotor cortex) that have recently been shown to play key roles in chronic pain therapeutics, so if I’m leaving it out, I’m not doing my job.
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2 Responses to Kolar, Cook and Moseley

  1. Nice post Dr. Cubos! I like the integreation of the different systems..There is no cookie cutter approach that works for all patients!

  2. Kenneth T. Cieslak, DC,ATC, CSCS says:

    Hello Dr. Cubos,

    I found your approach to be very similiar to my own, although I am not well versed in DNS principles yet, so I do not include that at this point. And I agree with Keats, each patient/athlete presents differently, and may require us to deviate off of our typical roadmap. As always, your blog presents us with excellent information, and I continue to plug it to colleagues, and plan on doing so again when I present at the NATA meeting next week. Keep up the good work!
    Ken

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