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For detailed information on this course, please click here -> Musculoskeletal Pain Syndromes

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Study Title:

Authors: G. Bronfort, R. Evans, A. Anderson, K. Svendson, Y. Bracha, R. Grimm

Journal: Annals of Internal Medicine

Date: 2012

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My thoughts

• First of all, seeing this study capture the attention of many manual and rehabilitation therapists through the power of the internet reminded me of the old “Start the Car” ikea commercial.

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• As a chiropractor that highly values exercise and rehabilitation, most would assume that I too would take this paper, “start the car”, and run away with it. Unfortunately, I wanted to read the actual paper and see what all the hype was about beyond the good publicity from the New York Times.
• There’s no question that I strongly believe manipulation and exercise may be better alternatives to medication in some if not many “pain” presentations, however, overtime I have learned to become more attached to patient-specific care more than anything else. Patient-specific care may indeed call for meds, manipulation and exercise – but patient-specific care may also call for reassurance, education, and / or soft tissue therapy.
• Now having read the actual study, the authors did do a relatively good job to prescribe individually based exercises but I do think they could have been more thorough. Gentle stretching and scapular retraction exercises, as well as neck and possibly (although not convincing in this paper) thoracic manipulations don’t cut it when it comes to sending a message that SMT and exercise are better than meds. I understand that this is a research paper so I will accept some limitations in the study.
• While there was significant difference in follow up at 6 months, no significant differences were found at the 1 year mark of follow up when compared to baseline. To me, this likely indicates symptomatic relief or treating the DP (which I think is ok)…but what about the root cause? And what about integrated care? Because how often do you just manipulate or just rehab? I know quite well many of you who read this blog also combine the two. But you probably combine other therapeutic approaches as well. What I don’t want to see is manipulating people’s necks for the simple reason that this paper said it was more beneficial. If it is indicated, and the patient consents, then by all means. But if not, don’t “start the car”. We need to be more precise and we need to be accountable.
• Again, it is a research study and I get that we can’t control for everything in research but I do think we can be a little more responsible when drinking the kool-aid. And responsibility means taking an objective, rather than emotional opinion…especially on social media. So please feel free to advocate that SMT and Exercise may sometimes be better a alternative than medication for neck pain (and that meds are often unnecessary), but please also recognize that generalizing the study’s results to all of your patients is an act that is no different than advocating for meds alone.

Bronfort, G et al. (2012). Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Annals of Internal Medicine, vol 156; 1-10.…

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Ken Crenshaw, Pavel Kolar, Lucie Oplova, Alena Kobesova, Sue Falsone, Rob Lardner, Clare Frank, Kathy Kumagai and Craig Liebenson

Along with the medical staff members of several major league baseball teams, prominent and budding physical therapists and chiropractors, I was fortunate to attend the “C” course, where our knowledge of the system was tested, advanced and enhanced throughout this 4-day learning weekend.

Because the “A” and “B” courses in this program form its foundation, this “C” course not only packages all the DNS principles together seamlessly, but also takes its principles to specific conditions whereby troubleshooting becomes much, much easier.

Now because I am a big fan of learning principles over specific tools and methods, the following information will be based on some of the key points that resonated best with me. My apologies for those that are new to the DNS system and may not be familiar with some of the concepts below. Should this be the case, please check out my review of the “A” course here prior to moving forward.

• One of the key tenets stressed in this course was the thorough understanding of the anticipated movements. Knowing what should “come next” and what you should expect, essentially will help guide and gauge whether you are right or wrong in your approach and treatment.
• When encountering troublesome hip problems, it may be wise to check the muscle activity and pressurization ability low down in the abdomen (near the groin) to assess for compensation. The body may be robbing Peter to pay Paul. Most, if not always, the goal should be balanced intraabdominal pressure throughout the entire cavity.

This is not a muffin top.

• Unilateral hip flexion is dependent on Thoracolumbar junction stability and contralateral hip stability, among other regions.This is based on the concept of the punctum fixum.
• Quite often, dysfunctions in neck stability/motor control stem from lower down the body. Just like the glenohumeral joint needs a stable scapulothoracic girdle, so too does the cervical spine. The “cannon from a canoe” concept applies here as well. Again, the importance of IAP cannot be stressed enough here.
• In chronic posterior chain dysfunction patients such as achilles tendinopathies, plantar sided foot pain, etc, again it would be more than wise to assess intraabdominal pressure. Trust me.

IAP: It's important, trust me.

• Too much concentric activity of the abdominals, pectorals, trapezius, etc may negatively affect the diaphragm’s ability to induce pressurization. The diaphragm and pelvic floor largely play a concentric role. All other muscles (i.e. above), are more important eccentrically.
• This is a no brainer, but a muscle’s ability to relax is very important.
• Gluteal filling (volume expansion) is important for lumbosacral and sacroiliac stabilization.
• Very often a lack of coordination of muscle activity is more important that a lack of strength. Proportion of muscle forces is important.
• Hips often do not need surgery, they need to improve their movement patterns.
• For stabilization, it is likely more important to simply hold the position (i.e. isometric holds) than dynamic repetitions.
• We can learn a lot from sumo wrestlers. They are very strong but rarely bench. They simply do thousands of centrated movements in a slow and controlled manner. Therefore, when working with young athletes, training a high number of centrated movement patterns is likely more important than loading.

DNS and Sumo Wrestling have more in common than you think

• It is always important to assess whether the problem is a contralateral pattern dysfunction or that of an ipsilateral pattern.
• In high tone/stress individuals, it may be wise to first start with mobilization and/or release. In persons possessing a parasympathetic state, load them up with stabilization.
• You can use which ever exercise progression you want, just respect the principles of a) centration and b) support and stepping functions.
• “Train the same pattern, only in different positions”
• The body’s ability to relax is related to body awareness. A lack of body awareness can be called “Body Blindness” – the inability to know the body, especially with the eyes closed.
• Low back (i.e. discogenic) patients with good quality of stereognosis (body awareness) will have a better likelihood of surgical success. Those who lack stereognosis would be wise to improve body awareness prior to surgical referral.

A different type of body awareness

• The principles of stereognotic training (which is based on Feldenkrais and Ayres) is slow, precise, repeated and simple movement with high central nervous system control. To me, it is the “recognise” of movement based rehabilitation. The objective is to learn to differentiate movement, controlled relaxation of the body with movement, and progression to higher level positions. Essentially, this may be an excellent intervention for motor morons.
• The goal of DNS rehabilitation is not only to improve the integrated spinal stabilizing system, but also to restore stereognosis. Therefore, Tai Chi may be an excellent method of physical activity for patients of all ages. As a side note, I’m really looking forward to Tai Cheng.
• DNS is not about the baby, it’s about optimal movement.

With Craig Liebenson, Ken Crenshaw, Pavel Kolar

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This circuit can be used by almost everyone, as I use this with cuff patients as well, but the key thing is to pay utmost attention to form.

The exercises shown in this video are:

• Bottoms Up Kettlebell Screwdriver for cuff stability
• Bottoms Up Kettlebell Armbar for cuff stability with scapulothoracic mobility
• Kettlebell Armbar for scapulothoracic mobility
• 1/4 Turkish Getup for scapulothoracic mobility and stability

*Note that for the “Getup”, I’ll always get them to perform the movement slower and post on the elbow but unfortunately I didn’t get it on video.

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*Disclaimer: I have not been formally trained in Kettlebells, so for those of you who are, your expert feedback is welcome.

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For those of you who have yet to read my posts on the previous courses, please take the time to read them below prior to moving forward.

• Dynamic Neuromuscular Stabilization “A”
• Dynamic Neuromuscular Stabilization “B”
• Dynamic Neuromuscular Stabilization “C”

So here are my thoughts.

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www.rehabps.com

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Assessment

Similar to the Selective Functional Movement Assessment, DNS has a series of tests within their system. And over the last several months but also this weekend, I have realized the importance of performing all the tests especially for those who are just starting out.  To me, getting into this habit ensures that clinical intervention is based on reasoning rather than assumption and provides the clinician with a global picture of the patient or athlete’s presentation. Regardless of whether they are performed at the beginning of the initial examination or in conjunction with other testing procedures, doing so may not only act as a filter for one’s current examination protocol, but may also lead to more effective stabilization strategies in rehabilitation.

Ultimately, the key link to the individual’s functional pathology must be found and finding this link will likely guide the practitioner to the most appropriate exercise intervention and, if necessary, the ideal reflex stimulation technique.

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Treatment

One of the most important recommendations I can give is to know the anticipated movements and understand the supporting and stepping pattern framework. Ultimately, the clinician can utilize whichever exercise progressions he or she wants but I cannot stress enough that when doing so, the principles discussed over during the courses must be respected. For those that are curious, I myself largely utilize progressions based on the neurodevelopmental perspective, principles that are common between the Functional Movement System and DNS.

For those of you who viewed my presentation on SCWebinars, you’ll know that I hold a high regard for variability. I was glad to see that Pavel held similar beliefs as well. And using a case example with an elite track and field athlete over the weekend, Pavel spent a great deal of time training a specific pattern (the key link) in a variety of positions. In so doing, variability was achieved and progress was made. The take home message, train the key pattern…in varied positions.

Whether you choose to utilize DNS-based exercises or your own, it is always important to pay close attention to joint centration. Shirley Sahrmann calls this the path of instantaneous center of rotation. The DNS goal however, is global centration. While DNS will utilize partial patterns to improve the global pattern, the true objective is to respect the power of each joint’s proprioceptive capabilities.

Also respect the punctum fixum. It is never a bad idea to go after the supporting structures prior to the phasic structures. In fact, it’s a great idea. Doing so will establish a better base of support and will give you a better chance to achieve optimal movement patterning. But be picky. As best as possible, try to refrain from cutting the patient some slack. Think about the 3 month supine position (similar to the dead bug) for example. When going after optimal intraabdominal pressure, one common mistake is to let the patient’s feet touch each other. The punctum fixum is the TL junction. Allowing them to touch their feet together will create a false punctum fixum. The direction of muscle pull is important.

I have mentioned this several times before but (borrowing from Gray Cook), you can’t train stabilizing structures with strengthening exercises. So when considering scapular stability and DNS, it will no longer be difficult to understand that the punctum fixum and centration concepts play huge roles in intervention strategies.  All 4’s positions (low kneeling) and side lying positions (RT 2 & 4) are excellent starts.

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Integration

It is important to realize that taking DNS courses doesn’t mean clinicians have to drop everything they have learned in and outside of school. DNS is about the principles not the methods. Use the tools you have, just respect the integrated spinal stabilizing system.

For example, I have found that DNS goes hand in hand with the Selective Functional Movement Assessment. If you’re familiar with the SFMA, you’ll know that its breakouts contain similar assessments to the DNS assessment. The supine neck flexion pattern test and the arm elevation pattern test are two that immediately come to mind. Now if you look at these to tests from the DNS perspective, you’ll know that they are both dependent on optimal intraabdominal pressure. Certainly joint mobility and tissue extensibility dysfunctions may be present, however, often dysfunctional presentations are secondary to faulty stabilization as well. As long as mobility restrictions are cleared, there’s no question DNS principles can easily be integrated into treatment. Just go after the pattern and if the patient can’t get it, that’s where the “magic” comes in.

Just don’t forget to reassess.

Another example can be found with thoracic extension and/or rotation restrictions. If this is your patient’s key link, you now have more tools in your toolbox to build better movement patterns. Remember, every exercise is a test so among others, you have the prone extension test and the bear to work with. And, if they cannot get it on their own or with guidance, (i.e. manual, resisted or verbal-assisted centration) then reflexive locomotion and stimulation may likely be your next tool in line.  Try the 1^st position. Try RT 3.

Those who attended the “A” course need not worry, the Reflex Creep position may serve you just well.

Recently, I’ve been asked for my clinical opinion on ideas for troublesome achlilles tendinopathy and chronic exertional compartment syndrome.  If you know me, you’ll know that my first response would be to look everywhere but the lower leg (save for the foot). You can do so via the SFMA and you can do so via Dr. Liebenson’s Mag 7. But you can also do so via DNS. A simple example? Again, the prone extension test. Faulty uprighting may just be the key link to lower limb posterior chain overload.

Rolling patterns have been quite the buzz for several years though unfortunately, mastering the art often isn’t easy. We’ll know that our patients need to be here in the algorithm but often performance difficulties will lead to frustration. One revelation for me this weekend was that the oblique trunk flexion test may be an excellent breakout for the flexion rolling pattern to shed light on the ability of the chest to stabilize against the oblique muscle chains. One solution for improving rolling patterns then? RT 2.

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I hope this sheds some light to the utility of DNS in practice. For those of you looking for some insight into my thoughts on DNS C, I’ll make sure to provide a little summary sometime later this week.

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I wrote about this last week in my post on shoulder mobility and AC joint separations, although I first heard about this concept in Gray Cook and Brett Jones’ “Secrets of the Core: The Backside” dvd.

To me, the premise behind this is a necessary stimulus for adaptation.

What I have found is that while the most contemporary strategies often get me the results I’m after, lately I’ve seen more rapid results when adding significant loads to appropriate movement. And by “appropriate”, I mean the most relevant exercise along the individuals rehabilitative or corrective exercise continuum. You know, the one (or two…maybe three), that through the clinical audit process results in an improved, pain-free movement pattern.

Take, for example, traditional rotator cuff exercises for glenohumeral dynamic stability. Some may choose to prescribe resistance band or cord work. Now granted, it has been suggested that it may be inappropriate to train stabilizers as movers, but I myself often choose to use bottoms up kettlebell screwdrivers.

Another example, which really opened my eyes this morning, pertained to the hip. I’ll admit that this example consists solely of “N=1″, but several weeks ago, I strained my lateral glutes, the stabilizers, by deadlifting the day after a long roadtrip through the mountains. Since then, I have been “doing everything right” to get myself back on track but the muscle fibers have been a little bit more stubborn than I would have hoped for. I’ve rolled my adductors and quads a ton, I’ve performed miniband glute work (bridges, lateral and reverse walks), added single leg squats and I’ve even had a fellow therapist poke me with her needles. But much to my dismay, no significant relief.

Well just last week, I decided take a chance and switch things up. I started performing heavy kettlebell swings, Turkish Getups and added weight to my single leg squats. Since today’s workout called for trap bar deadlift singles (I had continued with my program but decreased the weight significantly over the last few weeks), I wanted to experiment for myself what type of effect heavy loading can make on a strained glute. To ensure I was ready, I made sure to adequately “wake” up my core and brought my belt to the gym just in case.

Let me keep this story short. I hit 385 (don’t laugh, I used to be a triathlete and besides, I was only able to go 185 w/o pain just two weeks ago) on my last set which was absolutely pain free. In fact, the glute feels normal again.

Obviously, we’ll see what the next two days bring, but based on how I feel currently, I am confident that I am just about back to my pre-mishap state.

I will caution, however, that this approach may not work for everyone. Truly, there are certain individuals for which a more conservative approach is warranted. But for your (relatively) healthy individuals who are accustomed to aggressive physical activity, athletes for example, it may behoove you to load ‘em up.

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Load 'em up!

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Study Title:

Authors: DD. Juehring & MR. Barber

Journal: Journal of Bodywork and Movement Therapies

Date: October 2011

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• A relatively low level of evidence but a good read nonetheless. This recent case study published in the Journal of Bodywork and Movement Therapies described the use of the Vojta/Dynamic Neuromuscular Stabilization treatment strategy for chronic migraine symptoms in a 49-year old female. Hypothesized to be triggered via neural mechanisms, this type of headache has been described to be modulated supraspinally and often has been elusive to conventional treatment strategies. The specific treatment strategy reported was described (although not directly stated) to be via reflex stimulation of the breast zone in the first phase of reflex turning. For those of you who are unaware, the breast zone is located at the widest intercostal space between ribs 5-8, nearby the mamillary line. Subjective improvement was reported over the 12-week course of therapy via the Headache Disability Index and VAS pain scale measures, although there was no mention of any cognitive approach to care. Several other unsuccessful treatment strategies previously undertaken over the span of 20 years were mentioned, however, unfortunately no statements pertaining to follow up of this particular strategy could be found. Overall, I thought this was a good start to getting the efficacy of DNS in the English published literature, but I do recognize its limitations and that we still have a long way to go. In particular, I would like to see more advanced forms of DNS utilized in the literature, especially utilized in athletic populations, as well as published research with higher levels of evidence. That said, I myself have utilized this treatment approach in a variety of patients (athletic injuries, neurological pathologies, chronic pain, etc) often with very successful results, so I have no doubt of its positive effect on this 49-year old woman.

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Juehring DD & Barber MR. (2011). A case study utilizing Vojta/Dynamic Neuromuscular Stabilization therapy to control symptoms of a chronic migraine sufferer. Journal of Bodywork and Movement Therapies, 15; 538-541

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Hopefully most of you have already read my recap of Part “A”. If not, I request that you do so prior to moving forward.

This course was held just outside of Montreal, Quebec at a beautiful lake Resort approximately 70 km from the airport. Thank you to Caroline Vinet, DC for both organizing this course and offering her infant son as a subject for our educational purposes.

Led by excellent instructors Petra Valouchova, PT a certified Vojta therapist of the Prague School and Craig Morris, DC, this “B” course acted as an important compliment to “A”,with a heavy emphasis on expanding our knowledge of assessing, troubleshooting, and treating the developmental milestones as they apply to babies and relate to functional pathology in adult populations. It should be important to note that for those of you that have already taken the “A” course, it was highly stressed to us at this course that both “A” and “B” together form the foundation of understanding the DNS concept. Therefore, to truly understand its principles, I cannot recommend this “B” course enough. Because as Dr. Morris stated, “taking the ‘A’ course without the ‘B’ is just like having one foot.”

Since developmental kinesiology formed the foundation of this course, it is important to understand that at birth, the brain is an immature entity. I am certain that this is not new information for most if not all of you. At birth we are unable to move purposefully, we have no ability to maintain a secure base of support, and we are unable to produce co-activation/co-contraction for joint stability and load transference. Now the majority of us undergo relatively “normal” development as we age, however, those of us with functional pathologies often lack secure base of supports, supports that act as prerequisites for uprighting in development. Think of our ability to effectively swing a kettlebell, perform a solid Turkish Getup or throw a baseball. Without proximal stability, our distal mobility becomes inefficient. And it is important for us to understand that the functions of muscles change according to whether it possesses a stabilizing or stepping function at each instantaneous moment.

It was this concept of securing proximal stability or an efficient base of support that was highly stressed upon in Part “B”. Through a heavy emphasis on “workshopping” (approximately 85% of this 4-day course), we were able to gain a better understanding of uprighting with optimal stability. Specifically, uprighting through whole body joint centration really forced me to take a closer look at the strategies I had previously been employing for stabilizing isolated joint segments.

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Take for example scapular, core and hip stability. Naturally, this would depend on the state of the individual you are working with as well as your regressions and progressions but I, myself, have grown a liking to the “oblique sit” position. Centrating each of these in a Getup or modified side plank is as close as I can think of to the “oblique sit” so they may get you there faster than pushup plusses and clam shells.

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Doc Cheng gives a great example of this.

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Another major takeaway was improving thoracic extension. As an evolving therapist, there are many ways I can induce improved thoracic extension manually. Having said that, I have taken a liking to more active approaches and another one I learned this weekend was via the “first position.” Not too dissimilar to starting off in a child’s pose position, this technique with the help of reflex stimulation becomes an effective means for uprighting the thoracic spine through reflex creeping. Very effective for those with shoulder and neck dysfunctions if you ask me.

Speaking of reflex stimulation. You may have watched some of the videos on the Prague School’s website. While often DNS is thought of merely as a hands on approach eliciting magician-like reactions, the purpose of reflex stimulation is not so much to induce locomotion but more so a strategy to activate certain neuromuscular synergies and synapses. The result is the encouragement of certain partial patterns for the improvement of the global pattern. To me this means becomes more effective than cognitively initiated movement as it is highway-like in nature as opposed to the backroads of volitional control. And through the establishment of crucial points of support to which the body can pull toward, the end result becomes improved motor patterning.

For those rehabilitation professionals working with paediatric populations, I cannot recommend this course enough. We spent a great deal of time reviewing postural ontogenesis and assessing both primitive reflexes and postural reactions. With the help of two wonderful infants, we were able to enhance our understanding of baby’s optimal and faulty movement patterns as well as get a glimpse of the “hows” and “whys” dysfunction may be present today. In particular, while some of you may have no interest in caring medically for such populations, I do think it is important for many of us to have a basic understanding and ability to recognize abnormal development in neurologically intact babies.

As in all other DNS courses, there were certainly no shortage of clinical pearls and “ah ha” moments to get you thinking. Over thirty pages of notes were taken so let me share a few with you.

• There are two ways of training deep neck flexion. The first via repetition and the second via stabilization of the proximal segments. I choose the latter.
• Faulty muscle activation is often a sign of decentration
• One progression for intraabdominal pressure can be via pressurization in inhalation -> exhalation -> laterally -> posteriorly. The aim should be simultaneous pressurization along the above continuum
• In order to induce improved patterning, it is important to prescribe a home exercise program of an appropriate number of exercises (often very few) performed with excellent technique and quality for short durations with high frequencies
• There are several methods to treat disc pathologies. Most via passive means but few via active means (stability through centration). Certainly these may be simultaneous but it may be more effective to go after the active as soon as possible.
• “Joint centration is not just a biomechanical strategy, but also a neurophysiological one”
• The ideal method of reflex stimulation is often to stimulate more distally, via spatial summation (>2 zones), on contralateral or opposite (upper & lower) segments of the body.
• It is always wise to first start with the supporting zone/structure before facilitating the stepping limb
• “As long as the body is centrated, training anywhere along the pattern can be an exercise”
• Re: Anticipatory Patterns – the brain knows the movement, it is simply our job to elicit it

The unique thing about learning Dynamic Neuromuscular Stabilization is that we students are “living” in its evolution as Pavel Kolar is still relatively young. Unlike learning concepts from pioneers before us who have either passed or are in their later stages of life, the knowledge that we are gaining from DNS is constantly growing and evolving both with the research that he is conducting as well as that of the rest of the rehab world. Additionally, I can say with 100% confidence that DNS possesses some of the most brilliant and knowledgeable instructors that really make learning easy. As with any other course, be it related to rehabilitation or other, disseminating a concept from the complex to the simple is a difficult feat that really seems to come relatively easy for the instructors that I’ve had thus far. This certainly makes my life easier as I combine the knowledge that I have gained from my endless continuing education endeavors. So thank you to Petra and Craig, as well as Caroline and the rest of the delegates for a wonderful seminar!

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Some of the most enthusiastic delegates I've ever worked with.

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I look forward to meeting some of you at the upcoming “C” course at Athletes’ Performance in Arizona.

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If you have had the pleasure of attending one of Dr. Liebenson’s seminars, you’ll know first hand that he utilizes a large battery of exercises to rehabilitate a patient with functional pathology. While many of us attendees wished we were looking at the patient through his own lens, often we’ll ask ourselves “how the heck did he know that that exercise was the key link”?

Well in my opinion and aside from his extensive experience, there are two primary reasons why Craig can pull a specific exercise out from the score keeper’s room behind the Green Monster (let alone left field) and instantaneously help a patient improve their dysfunction. The first being the Clinical Audit Process and the second being a continuum of exercise progressions.

In the sport performance world, exercise progressions are to athletic development as I am to continuing education. And frankly, I don’t think the rehab world should be any different. Now I’m not talking about 8 repetitions this week and 10 repetitions next, but more so utilizing a continuum of exercises with similar objectives but with varying difficulties for the purpose of matching the right exercise to the said patient.

For those of you familiar with the FMS, you will know that Gray and Lee have their priorities and progressions. Pavel Kolar and DNS is not different and while I myself have never taken the RKC, I am quite confident that Pavel and his army are no different.

So in the rehab realm, how do we choose the most appropriate exercise for our patients? Well recently, Dr. Liebenson released his new 3-DVD set that answers just that. But as always, we must first start with a functional evaluation. Because without this, as Dr. Liebenson says, “any training flexibility, stability, or performance training is no more than dumb luck”. For more on functional evaluations, I highly suggest you attend one of his seminars, as well as that of the SFMA and Stuart McGill.

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So with these dvds, it is important to understand that it is the principles upon which corresponding exercises are chosen. Remember, it’s not about the tools but the principles behind them.

Core Stability Training

• For those of you in the rehab world, you probably already use several of these exercises already. Some of you may use them as your “core” exercises and others may simply use them to troubleshoot a specific patient. What some people fail to realize, however, is that Dr. Liebenson has been around since the invention of such exercises. Take McGill’s “big 3″ for example. Did you know that Stu and Craig have worked closely together for many years? To me, if I’m using specific exercises for my patients, I want to make sure that they are being performed correctly. And with this particular dvd (as well as the other two), Dr. Liebenson does an excellent job instructing each exercise and providing the most effective cues during their performance.

Overall, these dvds set themselves apart from many others not only because of the creator behind the discs, but also because of their professional quality. Utilizing custom-created images as well as “live” dialogues, Dr. Liebenson takes the time to explain with detail the purpose behind each exercise series. Certainly many more exercises will be invented but like I said, the principles behind the process are what’s most important. And it is these principles that will stick around in our industry for many years to come.

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Here’s what he had to say:

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Now because I’m a huge fan of “training the brain”, I decided to look a little deeper. I feel that I have a good understanding of the work of Moseley, Cook, and Kolar but this is a prime example of not knowing what I didn’t know.

Here’s a closer look at Brain Highways.

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Well now I know what I don’t know so it’s time for me to get after it.

Upon initial glance, this particular system and program seems to be relevant to anyone from health care professionals, to athletic development personnel, to teachers, and even to parents. I’m certainly going to put one foot in this door to take a sniff but hopefully, it’s aroma will be so pleasant that I’ll just have to dive in.

And once I do, I’ll be sure to give you my thoughts.

In the meantime, check out their blog. There are plenty of great reads!

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Train the Brain

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*note: the link to strength coach is of the affiliate variety for the sole purpose of funding my continuing education endeavors.

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For those of you who haven’t read their thoughts, here are the links:

• Corrective Exercise: Muscle Imbalances Revealed (Upper) – Eric Cressey
• Muscle Imbalances Revealed Upper Body Review – Mike Reinold

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Oozing with both practical and nerd-ical content, this dvd set is very comprehensive but also very user friendly. Grounded in scientific information, Eric and Mike presented various concepts ranging from the epidemiology and etiology of shoulder injuries to injury prevention and performance enhancement.

Here are some highlights from Optimal Shoulder Performance:

The importance of assessing Total Range of Motion

• Both Eric and Mike go into great detail to explain the importance of  the continual assessment shoulder total range of motion. Using the example of Glenohumeral Internal Rotation Deficit (GIRD) vs Instability, Eric and Mike explain why stretching the posterior capsule and cuff may not always be the best idea. In fact, they explain that doing so may even be pathological. So while the sleeper stretch has become a mainstay in many training centers, these two gentlemen provide their reasons why you probably shouldn’t be prescribing such exercise.

Dynamic Stability Progressions

• Supine to standing, stable to unstable, open to closed, Mike does an excellent job of introducing his exercise progressions for eliciting and achieving dynamic rotator cuff stability through rhythmic stabilization. I, myself, use his progressions quite frequently and really think this is a great way to “activate” the cuff prior to functional therapeutic exercise. In fact, I believe Eric may even use these progressions prior to training as well. The only downside with this type of exercise is that while gains can readily be made in clinical settings, there really wasn’t a similar exercise (that I knew of) to send the patient home with…until now. After several months of using this technique, especially early in the progression, I realized that bottoms up kettlebell work was a great way to repeat the objective at home. So here are two exercises that I now often sent my patients home with. The screwdriver and the armbar.

I believe Dr. Snell also uploaded this exercise on MyRehabExercise.com

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Note: For the complete exercise progression continuum for training dynamic cuff stability through rhythmic stabilization, I would highly suggest Mike’s Treatment of the Shoulder Joint Complex: Principles of Dynamic Stabilization DVD. You can pick it up at AdvancedCEU.com which, unsurprisingly, is an affiliate link to fund my “continuing education for life” endeavors.

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Impingement

• Going back to assessments, Eric and Mike use the differentiation between internal and external impingement ESPECIALLY as they relate to specific demographics to illustrate the importance of comprehensive assessments prior to training. Knowing your athlete history and choosing the most appropriate assessment recipe is can be a difficult thing to master but a trainable skill to practice nonetheless. It is often stated that if you’re not “assessing, you’re guessing” but how easy is it for us clinicians to simply assume and treat? Shooting for perfection 100% of the time will make us better practitioners and assessing will help us get there.

Practical Labs

• In the lab portions of the dvds, while Eric and Mike don’t dump the exercise tool box and give you all their exercises, they do spend plenty of time teaching proper form and optimal cueing strategies. I think this approach is far more important and effective than demonstrating hundreds of exercises. Because in each exercise, the principles stay the same – perfect form and proper joint positioning. That said, for those of you who are seeking an exercise database, they’re at your fingertips on each of their respective youtube channels. In fact, Mike has come out with some great exercises as of late so be sure to check out his page.

Finally, there were countless pearls embedded deep in the Optimal Shoulder Performance ocean. One specific pearl I liked was the fact that during rhythmic stabilizations, Mike almost wants the athlete fail on some of the reps. This is showing him that the exercise is difficult enough for the athlete to force an adaptation. Because like the clinical audit process, only with a significant but controllable challenge will a new pattern emerge.

All in all, I really enjoyed Optimal Shoulder Performance. It has provided me with excellent principles for effectively managing not only my 74 year old cuff patients but also my varsity swimmers. So if you work with overhead athletes, make sure you check it out.

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Why you might be the reason your child may be inactive – Tralee Pearce

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