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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Authors: L. McLaughlin, C.H. Goldsmith & K. Coleman

Journal: Manual Therapy

Date: 2011

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Summary:

• Here’s a short little study that evaluated the presence of poor respiratory chemistry in patients suffering from neck and low back pain, as well as the efficacy of biofeedback training on chemistry, pain and function. If you are a frequent reader of this blog then you’ll know that trunk muscles have a dual postural stability and respiratory function. You’ll also know that the presence of poor respiratory control may result in faulty thoracic, cervical, and scapular mechanics. Well the authors of this paper took a series of 29 cases with neck and/or back pain who failed conservative outpatient manual and rehabilitative therapy and studied whether or not they possessed poor respiratory chemistry.  Such (poor) chemistry was identified via a capnograph which measures CO2 levels at the end of a normal exhale.

A Capnograph measuring ETCO2 (normal 35-45 mmHg )

• Respiratory retraining was the main intervention in this study, consisting of awareness training, capnograph feedback, and manual therapy to improve mobility. Not only did the results demonstrate that all 29 patients possessed below normal ETCO2 levels, but outcome measures recorded improved in all patients following the intervention.
• While most, if not all, of you probably do not own a capnograph, this study does provide good evidence that 1) many of your patients suffering from neck and/or back pain probably also have some level of poor respiratory control, and 2) pain levels can improve following a clinical intervention that includes both respiratory training and manual mobilization.
• Unfortunately however, most physical therapy, chiropractic, athletic training, and massage therapy programs don’t include respiratory training techniques in their educational curriculum. So where can one find such information?

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Click on this recent blog post of mine to find out!

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2. The Balloon: Your New Clinical Tool Balloons, the diaphragm and intra-abdominal pressure....

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[slideshare id=7075688&doc=sedaugust2010-110226222253-phpapp02]

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“Functional Capacity Evaluation & Performance Enhancement” will be hosted by MSK-plus and will cover the following topics:

• Sacred Cows of exercise
• The Functional Screen
• The Magnificent 7
• The Clinical Audit Process (CAP): Finding the patient’s functional training range
• Core Controversies
• The Core Slings: Sagittal, Frontal & Transverse Plane Stability-Power System
• From fetal to upright posture the verticalization process
• Tri-planer function from the baby to the Olympian
• McGill & Kolar – biomechanics & developmental kinesiology where they intersect
• Gravity, workplace design flaws & training myths: A Postural Conspiracy
• Janda’s Movement Patterns – The orofacial-foot connection
• Balance – Soccer players to the elderly
• Subtalar Hyperpronation: What does the arm have to do with it?
• ACL Injuries in Females: What have we learned?
• The Challenging Spine Patient: Inflammation vs Sensitization
• The Overhead Athlete: Should they crawl before they throw?

I have had the pleasure of learning from Dr. Liebenson on MULTIPLE occasions and can say without a doubt that he is one of a very few individuals in the medical and rehabilitation fields who truly understands the spine. Dr. Liebenson has collaborated and learned from the likes of Janda, Lewitt, Kolar, McGill, McKenzie and others and through his experiences, has been able to concisely and effectively provide guidance to those following in his footsteps. His text, Rehabilitation of the Spine (2nd ed.) is perhaps the most comprehensive text of its kind and many of us are looking forward to the release of his new Functional Training Handbook, featuring the likes of Sue Falsone, Michael Boyle, Eric Cressey, Ben Kibler, and of course, Stu McGill.

For those of you who may have been living under a rock for a number of years and are unaware of Dr. Liebenson, then I suggest you visit his blog www.craigliebenson.com asap. There are no shortage of clinical pearls and thought provoking posts on this site and he has done an excellent job of utilizing the literature to translate the knowledge for our learning. Additionally, he had recently been interviewed  a number of times this past year so I encourage you to listen in as well.

• Interview with Dr. Perry Nickleston
• Interview with Dr. Brett Kinsler

“Functional Capacity Evaluation & Performance Enhancement” will certainly be a must-attend workshop so I strongly suggest you consider registering. The early bird cost (before March 1st) is $300 for students and $400 for professionals and this is in CANADIAN dollars so it is a win-win situation.

Hope to see you there!

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Performing the following exercise:

• The individual starts in a quadruped position on the floor with a neutral spine and the buttocks gently pressed against a stability ball.
• The hands are placed shoulder width apart directly beneath the shoulders and are actively engaging the floor.
• The neck is in a neutral position
• In order to achieve neutral spine, the individual is asked to both round and arch their back and then to find the “mid-point” between the two. A slight lordosis in the lumbar region is commonly observed.
• The individual then rocks back and “crushes” the ball behind him or her, maintaining stability in the cervical, thoracic and lumbar regions.
• As long as the individual is performing this movement well, a good sequence would be to have them hold the position according to a pyramid of 10 seconds, 9 seconds, 8 seconds, and so on.
• It is important that as he or she is “crushing” the ball, diaphragmatic breathing is maintained.

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Study Title: Cryotherapy to Treat Persistent Muscle Weakness After Joint Injury

Authors: C. Kuenze & J.M. Hart

Journal: The Physician and Sportsmedicine

Date: October, 2010

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Summary:

• This paper reviewed the potential beneficial effect of cryotherapy on a common clinical entity beyond that of pain or inflammation…muscle weakness. While muscle weakness following joint injury may be a product of a multitude of factors upstream of simple reflex inibition mechanisms, “arthrogenic muscle inhibition” caused by structural damage and / or effusion may nonetheless persist throughout post-injury rehabilitation and recover. Of particular concern is the potential for high-threshold or compensatory muscle activity when specific muscles being exercised are unable to fully activate. The authors of this paper reviewed several studies looking at the approach of cryotherapy on AMI. From the limited existing literature available, it was revealed that pre-rehabilitative cryotherapy may have a transient, disinhibitory efect on muscle recruitment ability. That while the mechanism of such intervention has still yet to be ascertained with certainty, the application of 20-30 minutes of “cryotherapy prior to therapeutic exercise (may) provide a method for clinicians to open the motoneuron pool prior to exercise to maximize effectiveness.”

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Kuenze, C. & Hart, J.M. (2010). Cryotherapy to treat muscle weakness after joint injury. The Physician and Sportsmedicine, 3 (38), 38-42.

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Study Title: Immediate effect on pain thresholds using active release technique on adductor strains: Pilot study.

Authors: A. Robb & J. Pajaczkowski

Journal: Journal of Bodywork & Movement Therapies

Date: January 2011

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Summary:

• Here is a nice little pilot study by two of my colleagues from Toronto on the effect of Active Release Techniques on immediate pain thresholds in elite ice hockey players. Using 9 players from AAA to the major junior level, they studied the influence of this popular manual therapy technique on its ability to modulate reported pain pressure thresholds (PPT) in acute adductor muscle strains. Up until now, the majority of the current literature on this technique had looked at the beneficial application of ART through case studies, however, few if any have looked deeper into the therapeutic effect of such protocols. PPT, “the minimal amount of pressure applied to the tissue to change the pressure sensation to discomfort or pain”,  was assessed both pre- and post-treatment via a hand-held mechanical pressure algometer. A significant improvement in PPT was demonstrated in this study. Since the painful experience involves both a bottom-up and top-down process, this study sheds some light into the potential positive effects manual therapy may have in acute pain patients. While the authors disclose that it is still difficult to conclude with certainty the exact pathophysiological and histological mechanisms responsible for these outcomes, they do provide some potential mechanisms for such reduction of pain. Certainly this study lacked a large sample size and randomization (hence a pilot study), however, the work of Drs. Robb and Pajaczkowski do pave the way for further research to validate a therapy that carries with it an extreme wealth of anecdotal evidence.

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Robb, A. & Pajaczkowski, J. (2011). Immediate effect on pain thresholds using active release technique on adductor strains: Pilot study. Journal of Bodywork and Movement Therapies, 15, 57-62

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Below you will find some of the PASSIVE methods a manual therapist can utilize to improved range of motion from deep posterior hip restrictions. Active methods can be found in Part 1. It is important to note that not all strategies will work for everyone. It will be up to you to figure out which one will work for each specific athlete, client, or patient.

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Posterior Hip Capsule

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Posterior Hip Musculature

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To give you a brief overview, the posterior hip capsule is innervated by articular branches of the Sciatic nerve (L4-S3). Without question, however, the capsule may also be innervated by articular branches of the Femoral nerve (L2-4) as well. Along with the deep posterior hip musculature (Piriformis and Triceps Coxae – Superior and Inferior Gamelli and Obturator Internus) that lie superficial to the capsule, it should be noted that the tendon of the Gluteus Minimus also sends its tendon through such capsule, not dissimilar to the Rectus Femoris anterolaterally.

Kinesiologically, the posterior hip capsule becomes important for normal hip mechanics. During hip flexion, should restriction of the tissues posteriorly be present, normal glide in this direction cannot occur. As such, Femoral Anterior Glide Syndrome occurs, somewhat similar to what occurs during internal impingement of the shoulder. In the lay person, this often occurs as a result a chronic slouched posture while seated and in athletes this may be demonstrated by the presence of a strong posterior tilt at the bottom of a squat.

Upon physical examination, it is not uncommon to find a firm capsular end feel. The dysfunctional capsular pattern of the hip will first be revealed by a marked restriction of internal rotation.

Techniques that may be utilized to improve hip mobility include, but are not limited to, Muscle Energy Techniques, Mulligan Mobilizations with Movement, Active Release Techniques, various grade Manipulations, etc. Some of these are demonstrated below. As mentioned above, it is important to note that not all strategies will work for all individuals. It is up to the manual therapist to identify out which one will work for each specific athlete, client, or patient.

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In viewing SportsRehabExpert.com founder, Joe Heiler, perform the Mulligan Mobilization with Movement technique above, it should be noted that many other variations of this technique can be performed to mobilize the posterior hip. Specifically, several of the techniques I demonstrated in the first video can be performed with such accessory glides.

I am hoping to receive a video from Dr. Andre Spina, outlining his version of posterior hip mobilization using the Functional Range Release soft tissue management system. In the meantime, however, I ask that you view the following video to introduce yourself to the theory behind his technique.

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Circle gets the square!

• Tell them that they should act like a sumo wrestler and utilize their hips every time they lift, bend, sit, etc. Not only does this include when they sit on a toilet but also when they wipe with TP.
• Watch them get into their vehicle. Ask them to drive that right foot as close to the gas pedal as possible so that they may be able to utilize the sumo technique described above.
• Ask them to make sure that they always maintain a neutral spine. You’ll probably need to demonstrate and explain what this is.
• When getting up off a chair, tell them they need to “spread the floor“. This is a technique the powerlifters use when squatting heavy weight in order to maximize gluteal recruitment and subsequently, hip joint involvement.
• When necessary, ask them to utilize a low level abdominal brace to ensure volitional stability. This may not be necessary when they fully recover but while their still suffering, it is important.

Simple stuff folks. Kinda like using the john.

Look forward. Adopt a wide stance. Hold the load close. Ensure a tight grip. Breathe.

So before you apply the latest and greatest of manual and rehabilitative techniques on your patient, make sure that you are first removing the aggravating factors!

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From the looks of it, I will hypothesize that the three-fold objective is to activate the Transversus Abdominis (TrA) via a hollowing maneuver, the pelvic floor, and the gluteal musculature.

There has certainly been much academic debate surrounding the role of specific musculature in low back rehabilitation, so if you are unfamiliar with this controversy, may I suggest that you first take a gander at my review of the spine control symposium held in August of 2010.

But back to the suck, squeeze & squeeze.

Not only do I have some doubts that this is the most ideal way to initiate the rehabilitation of an individual with low back pain and dysfunction, but I most certainly disagree that one should be performing such techniques at the 4, 6, and even 12 week mark of rehab. There are many reasons why I do not think this is favorable but the majority of my concerns pertained to no mention of the diaphragm as well as a purely volitional act of contraction. That said, understanding that this is a debate in rehabilitation, I sent Dr. Charlie Weingroff (a physical therapist) an email to seek out his opinion.

Here are his thoughts…

Jeff, I’ve watched the video, and I can make some assumptions and thoughts. But just based off the video, there appears to be a lot more information that I would like to see and learn before passing judgement.

At this small glance, it appears these folks believe that establishing an isolated contraction of magnitude in these major players in the core, then it will automatically add up to appropriate function. Sometimes this works. Sometimes it does not. And when there is a more reliable approach to get the key muscles’ activation and within a meaningful movement indicator, I think it would cast an aspersion on this approach.

So the Suck is the draw-in of the navel. We’ve talked about this before, and I believe it to be completely unacceptable. The reliable approach to “reset” the core is the diaphragmatic breath and unyielding to IAP. It is humanly impossible to deliver this quality of breath in the presence of a draw-in. There is no disputing the TrA activation of the draw-in or its role in spinal stability, but its isolated activation, which is not functional, at the expense of a valuable indicator of function, the circumferentially expanding breath, is not valuable.

The 1st Squeeze is of the Pelvic Floor. This is interesting because the literature of training methods of each of the inner core muscles, the pelvic floor has the 2nd best results behind training the diaphragm. I believe this to be the case as it is still in the sagital plane, and sagital stabilization appears to be the priority in repatterning. I often try to explain the inner core/IAP as a function of a parachute. This will be explained better on my DVD, but the very small part of the parachute is the Deep Neck Flexors. The large parachute itself is the diaphragm. The strings in front are the TrA, in back the Multifidus, and the jumper is the pelvic floor. In a normal jump, the chute opens, and when there is enough air under the parachute, it tensions, and all the other components tension.
Now if you jumped with the chute already opened, the jumper would tension first, then the strings, then the chute. This could still lead to a safe flight, and it was the jumper/pelvic floor that started the feedforward mechanism.


This is why I think there can be good results with the pelvic floor, but it is also dependent on the symmetry of the Multifidus who is often discussed as an issue. I believe that symmetry is attenuated when the diaphragm drives the mechanism given its lateral span of the body and more direct connections of the thorax.

The 2nd Squeeze is of the Glutes. This is a very underrated approach to acute back pain, and it is really quite simple. In the presence of pain and/or dysfunction, there is a guide towards an anterior pelvic tilt and approximation of lumbar vertebrae. This is form closure. When you posteriorly pelvic tilt with an aggressive glute squeeze, the lumbar vertebrae traction and gap. This is very good because I believe the zygopophyseal casules send signals to the brain to guide more towards force closure through the core. I think this is an excellent choice to add in to remediate acute low back pain and begin to restore mobility. If extension patterning has ERP, a glute squeeze can gap the impingement and allow for a successful extension technique. Anteriorly, the posterior pelvic yields reciprocal inhibition of the hip flexors, which is another environmental keyhole into appropriate force closure through the spine.

So each of the components of Suck, Squeeze, and Squeeze have varying levels of merit. I like the glute squeeze the best. Selective activation of the pelvic floor has merit as well, and I have read Stuart McGill ask that we focus on holding in a fart rather than “squeezing the pelvic floor.” (note: see the Internal vs External Focus for Skill Transfer section of this post)

Sucking in the navel is a very poor choice and should be avoided. Again, it changes the punctum fixum of the diaphragm and inhibits its ability to descend during contraction. If the volitional training gets you to a reflexive success, then this can work. I am not just not sure it’s the best way to get it done. Breathing techniques, for my money in developmental positions described by Vojta, get you a lot more mileage.

Hope this helps.

Thank you Charlie for your insights and contribution. I most certainly agree that more information should be collected prior to passing judgement. Perhaps, I jumped the gun on this one. However, I do believe that there may be more effective methods for achieving normalcy in low back dysfunction.

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36 year old retired hockey player.

Long history of low back pain.

Radiation down the lateral aspect of the leg to the foot.

Discogenic right?

Maybe.

However, pain was not worse with coughing or sneezing and a sudden weakness of the right foot became apparent.

Know this guy? He might be of some help.

A motor weakness was found distally in the right lower limb and the deep tendon reflexes were within normal limits (2+). Notably, an “up-going toe” was revealed on the same limb. This is a significant sign as “down-going” is considered a “normal” response.

Along with other specific tests, such findings may indicate an upper motor neuron lesion so it is important that we keep our clinical examination skills equally as sharp as our history taking.

You just never know when something may be hiding in the bushes!

If this post seemed brief, it was supposed to. It was simply a reminder that your examination shouldn’t be…

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YOU!

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You see, the way people think, affect the way people feel. And the way you interact with your patients, may affect the way your patients think.

As you may or may not know, chronic pain is a disease in and of itself and is, by and large, rarely a reflection of diseased or injured tissue. In a musculoskeletal sense, injured tissues generally take weeks, maybe months, to fully recover and the normal healing process typically dictates proper plan of management. But for the most part, a proper plan of management must respect the stages of “healing”.

Let me ask you this…

• In the acute phase, do you chase the pain and perpetuate? Or do you medicate and manipulate and EDUCATE?

• In the subacute phase, do you over-perform passive care and still chase the pain? Or do you provide self-care exercise and EXPLAIN?

• In the chronic phase, do you coddle the patient while you search for the magic cure? Or do you interact with the patient, expose in a graded fashion and REASSURE?

So in the event that you are unsure as to what I mean by the above, may I kindly suggest that you grab a snack and watch this video from one of my lectures in the University of Alberta’s Certificate in Pain Management program through the Faculty of Rehabilitation Medicine.

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Press play to watch the video

*Please note that I am not advocating medication and manipulation for all acute patients, this was simply an example.

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