Dynamic Neuromuscular Stabilization - B

Very recently, I had the opportunity to attend Part "B" of the Dynamic Neuromuscular Stabilization series of courses. For those of you who are unaware, DNS was developed by Pavel Kolar, originates from the Prague School of Rehabilitation and is strongly influenced by Vladmir Janda, Karel Lewit, Vaclav Vojta and Frantisek Vele. An approach targeting the integrated stabilizing system and based on the principles of developmental kinesiology, this strategy of rehabilitation provides the student (read: health care practitioner) with a better understanding of the neurophysiology of the locomotor system.

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.

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.

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!