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.
• 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.
• 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.
• 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.
• 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.

Having studied under Craig Liebenson for quite some time, I have developed a better appreciation for the McKenzie Mechanical Diagnosis and Therapy system. Seeing Dr. Liebenson relentlessly "audit" his patients, and understanding that this audit forms the foundation of McKenzie principles, the reassessment has become a cornerstone in the management of my patients.

As such, and to gain a better understanding of this system, I decided to host McKenzie "A" - The Lumbar Spine at my clinic.

It truly is more than centralization.

Apparently, this was the first course held in Canada that combined physical therapists and chiropractors as delegates. To me this was significant as I have always held the belief that who you are is more important than what you are.

Now the key take away from this course was perhaps the first statement made by our instructor, Audrey Long.

"It's about applying the right thing to the right patient"

To me, the above statement means conducting a thorough and accurate assessment, applying the appropriate management strategy, and reassessing to confirm the effectiveness of that strategy. So it was clear to me that McKenzie MDT was more of an assessment method than a treatment method.

The second principle learned from this course was another "Craig-ism"...the importance of self-care. That it is very important that we first utilize an active, hands off, approach in order to allow the patient to learn about the treatment experience. Taking this approach promotes independence and a better understanding (by the patient) that they have the power to "make themselves feel better".

Now it is still considered manual therapy, better decision making is just employed to determine when and when not to put one's hands on the patient.

One important key to a thorough assessment is the patient history, and understanding why they got there in the first place. Quite often it is what they didn't do, rather than what they did, but it is also likely related to their tendencies. Do they sit all day? Do they stand all day? Are they constantly bending? Are they constantly twisting? Or...do they have faulty movement patterns?

While the philosophy that surrounds this method of treatment lies in the clinical audit process, there is no question that most therapists equate McKenzie MDT to discogenic pathologies. And for good reason.

However, quite often such pathologies, especially of the acute variety, present with pain induced sympathetic overload and/or faulty core function secondary to high threshold strategies.

For the latter, often the patient presents with antalgia and obvious signs including, but not limited to, guarding, sweating, fear of movement, etc. In such cases, for me to put them through repeated movement testing from the get go, may not be the best approach. Some therapists will often use ice, IFC and e-stim, but for me, I would rather unwind the system that's on lockdown. And by that I mean, decreasing the threat.

Patrick Ward recently wrote about the Parasympathetic Nervous System. For me, the methods I often use are crocodile breathing, gentle perturbations rib cage and hip mobilizations, soft bracing as per Stu McGill, reactive neuromuscular training and reflex stimulation...all dependent on patient presentation. And ALL with appropriate (read reassuring) communication.

I will also groove proper hip hinging and thoracic uprighting. But following that, and when appropriate, I would then implement centralization methods. Likely on the first visit but always with respiratory control.

Ultimately though, my goal aside from the above history, would be to understand why the individual mechanically sustained the injury to begin with. And this is where the SFMA fits in...to respect the high threshold strategy. This is also where Stuart McGill's strategies come in. Sometimes prior to calling off security, and sometimes after. But definitely always.

I admit that I am still having difficulties with my understanding of McKenzie methods. Not only because this method "tissue-fies" many pain presentations, but also because I believe there may be more appropriate ways to assess and "treat" with repeated movement in very acute conditions. Our instructor suggested that,  "we should stick with McKenzie and not mix systems (i.e. stability and muscle imbalances)" and to me, this may not be the best approach. I truly believe that the patient should take priority over the method and therefore, I will continue to do what I feel is most appropriate.

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. 

The Book Movement just came to life.

Here's a recap:

Gray Cook on Profiling Movement

• We sometimes view movement through a filter. A filter which is based on our backgrounds, be it our techniques, professions, or specializations. The goal of the FMS team is to talk about the principles because we all need standardized principles to govern our principles.  The principles of which they speak are based on the neurodevelopmental perspective, a perspective that is based itself on motor learning, and trial and error. Think of babies...in order to improve movement, they must learn it.
• With respect to fundamental movement patterns, it is important to know if the individual is a) competent and b) symmetrical. Delving into competency a little deeper, consider vision. In order to obtain your drivers license, you must first take a vision test. Therefore, first establish competency, then go after performance.
• Dentists are smart. They make you come in twice per year for check ups (screens). This standardization is important. The functional movement system model is all about a "standard operating procedure". Pilots figured it out. Due to the risk of death, they collectively established a standard operating procedure, a checklist, prior to flying. Death is not a risk in movement. This is why we have faulty movement patterns.

"We have risk factors for every organ in the body...except the neuromusculoskeletal system"

"Don't change your system, just throw a movement competency system in front of it"

"Movement pattern atrophy...it's possible"

• Athletic performance is defined by durability. Athletes cannot perform if they're not on the field.
• The NSCA requires CPR for certification. But you don't see heart attacks in the weight room, you see a bunch of people in the squat rack with a bunch of injuries
• Stiffness (i.e. in low back pain) is a strategy. A compensation for poor motor control. To slow you down and prevent you from further injury. This is your parking brake.
• Strength training stabilizers is not stabilization training.
• True stability should really be called motor control. Movement pattern improvement is a product of motor control, which is a product of stiffness (or lack thereof). Therefore, first clear mobility to minimize compensation in order to improve motor control.
• You can treat the pain, just don't exercise the painful pattern.
• Don't bring expert evaluation to the screen. Call it like it is. Then group them based on the screen and move on.
• Motor control isn't just about activating a muscle, it may also be about deactivating another. To move efficiently, the body must be safe. It cannot be threatened. Sometimes we just need to find a way to remove the parking brake. Because typically, we're already strong enough. We simply lack the stability-motor control.
• Clinically, we must first treat the dysfunctional non-painful in order to assess its influence on the painful area. Treating the painful area first may only exacerbate the problem.

"Don't be tied to your methods...be tied to your systems and principles".

Phil Plisky

"It's not about the natural history of pain and injury, it's about the recurrence rate"

Kyle Kiesel on the Functional Movement Screen

• Always think about the bigger picture
• "Whether you are a waiter or a brain scientist, if you want to get the particulars correct, in a hierarchical fashion, don’t start with the details. Start with the key ideas and, in a hierarchical fashion, form the details around these larger notions." - John Medina, Brain Rules
• How to use the FMS. 1) Near discharge to bridge the gap from rehab to fitness. 2) To help with return to sport and sport decision making. 3) To help with injury prediction

Greg Rose & Gray Cook on the Selective Functional Movement Assessment

• It's about the assessment and the logic behind the assessment.
• On proprioception - there's no input into the system if the joint can't move. The true definition of motor control also includes adequate mobility. This is Charlie's core pendulum theory.
• If the body doesn't know what to do, the first thing the body does is create stiffness or achieve control in a different manner.
• Mobility and stability form the foundation of the SFMA

"Our diagnostics (our thought process and clinical decision making) is just logic"

• Breaking the movement down magnifies the problem. First do gross movement, because too often we break it down before looking at the big picture. Think about Usain Bolt. Let's say his multisegmental flexion (toe touch pattern) is good, yet his active straight leg raise is limited...would you go after his ASLR?
• The SFMA is simply a roadmap, it tells you where to go so that you can utilize the most appropriate tool in your toolbox (Graston, ART, Needling, etc).
• The SFMA scoring system i based on 2 questions. 1) Did it hurt? and 2) Was the movement good or bad?
• Most of the time, the region that is hurting is the region that is doing something right.

The Rules of Screening

• No warm up
• If it looks like a dog and smells like a dog...call it like it is!
• Be picky. The bottom line is, if you think you can make it better, it's dysfunctional
• No shoes
• Monkey see, monkey do. Demonstrate the movement you want to see. Unfortunately, problems arise when you can't perform the movement yourself.

"It's not magic, it was just a stability problem".

• No coaching in the SFMA. Monkey see, monkey do.

"Never bring a mobility problem to a stability correction...DON'T BE A ROOKIE!"

• Don't skip steps. More mistakes are made in the examination because of not looking than for a lack of knowledge.
• Most stability problems aren't strength problems, they're motor control problems.
• Once you find the white elephant (the big Dysfunctional Non-painful pattern), it just becomes logic

Kyle Kiesel on Pain and Motor Control

• Kyle started off this lecture by introducing to us a recently published paper by Hodges and Tucker.
• The new pain theory:

1. Redistribution of firing between and within muscles
2. Involves changes at multiple levels of the motor system
3. Leads to protection from further pain and injury
4. This adaptation has short term benefit and long term consequences
5. It changes mechanical behavior and modifies movement

"We don't need more injury prevention programs, we need a better system" - Phil Plisky

Mike Voight  on Breaking Down Function

“If you train the muscle you may not completely develop the movement, but if you train the movement the muscle will develop appropriately!”

• The importance of mobility and stability for efficient movement. Compensations and incorrect mechanics secondary to deficient mobility and stability may result in inefficiency and increased energy expenditure, possibly leading to poor performance and injury. Thus, mobility and stability testing as the starting point for “functional” rehabilitation.

SFMA Breakouts 101

• Unilateral vs Bilateral
• Loaded vs Unloaded
• Active vs Passive
• Consistent vs Inconsistent

Greg Rose on Functional Training

• Functional training is motor learning
• If you are doing functional training, the above book is the first book you should ever reed.

• We need to be experts in motor control. We need to be neurofunctional trainers
• Cognitive skills are easy to lose. Motor skills are difficult to learn. Focus on feel, not form. Because what matters is the discovery...the learning.
• There are three phases to learning - 1) Discovery 2) Grooving 3) Automatic
• We must do a retention test after practice to gauge learning. This is the clinical audit process. This retention test is the SFMA.
• The more the individual struggles with the exercise (as long as they perform it relatively well) during the visit, the less change of injury tomorrow. If you exercise on a machine that doesn't let you make a mistake, you're not learning
• On feedback - The less the feedback, the more the learning. Intrinsic oriented feedback (what the individual feels) >>> results oriented feedback.

The Functional Continuum

• Subconscious dysfunction (screen here)
• Conscious dysfunction (reset, reinforce here)
• Conscious function (reload here - motor learning)
• Subconscious function (improvement)

The 4x4 Matrix for Reloading a Stability Problem

4 Functional Positions

1. Non weight bearing (supine, prone)
2. Quadruped (I assume also triped)
3. Kneeling
4. Standing

4 Functional Exercise Resistances

1. No external load with pattern assistance (*an example of pattern assistance is RNT - Reactive Neurmuscular Training)
2. No external load
3. External load with pattern assistance
4. External load

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!

Progressions, progressions, progressions.

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 or SFG, 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.

Earlier this year, Eric and Mike released a 4 disc, 8 part dvd set titled, Optimal Shoulder Performance. Because of their extensive experience and diverse yet seamless backgrounds, this product is a great resource for any sport medicine and/or performance professional working with overhead athletes. While I consider myself a "hockey guy", I do get my fair share of baseball players and work closely with a varsity swim team so the information contained really resonated well with me.

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.

This weekend, I had the pleasure of attending a CE course in MY OWN BACKYARD! Those of you who've visited this blog before will know that I probably spend 150% of my income on flights for continuing education so this was a welcome change.

The course I attended was "The Integrated Core: Harnessing the Diaphragm / Pelvic Floor Piston" with physical therapist, Julie Wiebe. While I admit that I'm a diaphragm guy, I have always recognized the importance of the pelvic floor but have really ignored it. Perhaps it's because I'm male and perhaps it's because people with urinary incontinence (i.e. post-partum women) rarely knock on my door for treatment. And while both this topic and course were definitely out of my comfort zone, I was really glad I attended this course.

Both feet were definitely out this weekend!Here are some takeaways to illustrate why:

• Julie views the muscles of the "core" as analogous to the gears of a system with each muscle interacting with each other for an end purpose. It's negligent to only polish one gear (i.e. Transversus Abdominis) and ignore the others.
• The core is a dynamic system. We don't want to statically hold one gear because it will stop the entire system. So stop hollowing, holding your kegels and holding your breath.
• Like the diaphragm, the pelvic floor also plays a role in postural stability since its activity becomes synchronous with the abdominals during movement.
• Speaking of the diaphragm, we all know that it plays a huge role for creating intraabdominal pressure. But remember, it needs to pelvic floor to create IAP against.
• The diaphragm and pelvic floor sets up IAP for inspiratory stability and creates elastic loading of the pelvic floor / transversus for expiratory stability.
• The breathing strategy Julie espouses is the "umbrella breath". I think this is a great strategy to facilitate lateral rib cage expansion. I'll admit that I may have swung too far on the belly breath pendulum and will probably be cueing the umbrella breath a little more.
• The vestibular system contributes to the sensory information that the diaphragm receives for the facilitation of postural stability (note: can someone share some Z-health info with me?)
• To optimize pelvic floor contractility in rehabilitation, it is important to send your patients to the bathroom prior to exercise.
• The male pelvic floor is shaped more like a cone resulting in a greater actin/myosin relationship
• The female pelvic floor is more broad shaped resulting in less ability to generate force. Note that this differentiation in shape begins at puberty and therefore, may likely play a role in core deficiencies (young females lack a neuromuscular spurt) related to ACL disruption.
• Post-partum females return to neurodevelopmental low-tone states
• Optimal diaphragmatic activity improves lower thoracic and upper lumbar mobility
• The pelvic floor is comprised mostly of slow twitch fibers. Therefore this may fall in line with Janda's work relating to inhibition.
• The pelvic floor is innervated by S2-5. So are the intrinsic muscles of the feet!
• A neutral spine increases the resting tone of the pelvic floor
• Anterior weight shift facilitates anterior pelvic floor activation (which is more prone to dysfunction)
• Adductor activity facilitates neural overflow into the pelvic floor (note: you can get more information about this from the Postural Restoration Institute)
• Cue a "lift" to facilitate the pelvic floor. Cue a "close" to facilitate the urogenital diaphragm (which is more fast twitch)
• Re: Rehabilitative Exercise of the generic variety - "supporting (facilitating) their weaknesses is feeding into their compensations" (read: each program must be individualized)

Overall, while I did enjoy this course, I have to admit that I still have to study this topic further and let it simmer. Clearly, the pelvic floor has a tremendous role to play in the "core", as all other muscles do, however integrating my learning from this weekend into daily practice will probably take some time.

As a medical practitioner trained in the Advanced Selective Functional Movement Assessment, I recently had the privilege of attending the Functional Movement Systems' internship program. Held in Evansville, Indiana, this 3 1/2 day workshop was a means to train specific practitioners in the overall integration of the Functional Movement System.

Taking things back to the FMS, another highlight of this internship was a conference call / webinar with Rob Butler of Duke University. Rob has been heavily involved in FMS research as of late so this was an excellent way for each of us to truly understand the literature behind their system. Aside from providing us with a comprehensive review of the current literature as well as studies in progress, Rob also provided us with some notable quotes that really shed some light into what we are dealing with.

"MDs want and MRI...I want an FMS, SFMA, and Y Balance"

"Why is a dysfunctional deep squat a medical emergency at 2 years old but not at 14 years?"

"Can we upload a better motor program?"

"We need to clear fundamental movement...'but it hasn't been shown in research'...ya, but what else has?"

"FMS & Y Balance, the portable gait lab"

"When you screen someone, you're telling them something they already know...but now you're objectifying and quantifying it"

"Y Balance - to test for if...FMS - to test for why"

Another significant component to this internship was the application of the system into our everyday practices, be it the athletic or clinical setting. Each delegate was to present a case study where the group was to both critique and provide recommendations to enhance our learning. Interestingly, Kyle also provided us with a rounds type of case presentation that to our benefit, resulted in the incorporation of dry needling in treatment. One of the delegates was a therapist from kinetacore, so he was kind enough to demonstrate the use of needling in a live scenario. The video below is not of the actual case but of another delegate receiving treatment for a neck complaint.

Typically upon attending a course, workshop, seminar or conference, I write a recap not only to share information with all of you, but also to review what I have learned. This process generally facilitates a better understanding of the concepts covered and allows those reading to gain a better insight into specific courses that they may have yet to take.

Here are several examples:

• Diagnosis & Management of Tendinopathies (2011 Pan Pacific Conference of Medicine & Science in Sport)
• Fascia the Forgotten Tissue (notes courtesy of Dr. Thomas Lam)
• Building the Ultimate Back with Dr. Stuart McGill
• Dynamic Neuromuscular Stabilization - A

This past weekend, I had the opportunity to assist Dr. Liebenson with his Functional Capacity Evaluation & Performance Enhancement workshop hosted by MSK-Plus.