Dynamic Neuromuscular Stabilization - Review

Recently Craig Liebenson hosted Pavel Kolar and his Dynamic Neuromuscular Stabilization courses at Athletes' Performance. As an attendee of the "C" course, I had the opportunity to strengthen my understanding of the DNS principles as well as improve my skills learned from my previous experiences at the "A" and "B" courses.

The impetus for this review stems from being asked several times by different friends and colleagues how I've integrated the DNS principles and techniques into my current practice.

So here are my thoughts.

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.

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.

Some of you are aware 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.

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 1st 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.

I hope this sheds some light to the utility of DNS in practice.