It's been over a year since I first began the Dynamic Neuromuscular Stabilization program. Since that initial "A" course, my clinical thought process has expanded exponentially through following up with the "B" and "C" courses, my privileged opportunity to visit Motol in Prague, and the day to day reflections of my current practice.
Well recently, I had the privilege of taking part in another DNS A course that was put forth by Michael Maxwell of Somatic Senses and taught by Alena Kobesova and Brett Winchester. This particular experience was quite special for me because not only was it local (hence no flight costs), but it provided me with the opportunity to share my experiences to date with many of my friends and colleagues who attended the course...including my wife.
I would say however, that the most beneficial aspect of being present was that it afforded me the opportunity to "fill in the gaps".
Now while I would say that my current understanding of the DNS approach ("it's not a technique, it's an APPROACH") is quite solid, I do believe that like sport, it certainly will take years of deliberate practice to master.
So let me share some of the knowledge shared throughout this most recent course that helped me fill in the gaps. Some of the information below will be based on the course material and others will be based on my thought processes as my mind traveled a million miles a minute. As always, please remember that these were my own interpretations. And for those of you who have yet to read my previous reviews, please make sure you click on the links above.
Here we go...
In general, there are two schools of thought to Musculoskeletal Medicine: Structure and Function. While we normally focus on structure, it is often forgotten that we really cannot have one without the other. And while in our later years (especially in today’s society) structure may certainly play a role in dictating function, in developmental kinesiology, it is known that function governs structure. Therefore, viewing MSK medicine in this light may provide us with a more accurate model of care.
The unfortunate news however, is that unlike anatomy, functional norms have still yet to be clearly defined. If you look at bodybuilders, martial artists and runway models, which of the three would you say is the ideal? I know what you are thinking but is there a "why" to your answer? If you think about it, babies no nothing about bodybuilding, martial arts and modeling, they simply achieve “normal” posture on their own...using neurophysiology to change (aka develop) their own posture to explore the world.
"It’s not just that the baby 'grow’s up'…it’s CNS development."
Therefore, developmental patterns are related to the environment and are likely ideal. And this gives us every reason to study developmental kinesiology.
Speaking of development, the arch of the foot forms around 4 years of age. So if a mother brings in her 3 year old child to your clinic because little Johnny has flat feet, just agree…and don’t put orthotics underneath the child’s feet! (Disclaimer, you do have every reason to evaluate for dysfunction however)
Many of you are familiar with Stuart McGill's work. And many of you are likely aware that much of his research investigates loads on the spine. Like McGill, it was stressed within the course that it is often not external load that really hurts us, but internal load. That is, the load placed on our bodies through muscular contraction. Because lacking functional joint centration (maximal instantaneous congruency between two joint surfaces) decreases balanced activity between musculature, resulting in relative muscle hyperactivity. And it is this relative muscle hyperactivity that exceeds the body's physiological capacity resulting in potential injury (amongst other potential mechanisms of course).
One example to conceptualize is the hamstring strain. Often the common explanation is a "weak glute". This may or may not be the case but consider decentration of the opposite foot sending a "chain-reaction" up the body, resulting in compensatory hyperactivity of supposedly stabilizing muscles. Therefore rendering (for example, the hamstring) a victim due to its new found force generation responsibilities. Because as the DNS folk would put it, a deficient punctum fixum results in greater activity of its associated muscles, likely leading to strain or tear due to compensation from contributing to the deficient punctum fixum. It's a ripple effect, if you will.
Note: If you're "releasing" an acute hamstring strain you may be missing the boat.
Speaking of which,
“Are you treating the body’s compensations? Or on what’s wrong/the cause of dysfunction?”
The moral of the story...if one segment is dysfunctional, it can compromise the whole system. Search for the key link!
Another gap filler I took home with me was the importance of the sensory system. From tactile sensation to proprioception, optic, vestibular and acoustic, Janda taught that we must respect the bottom up approach of environmental feedback during clinical management. I previously wrote about the short foot but for those of you unaware, the inability to attain a short foot (what I call "dead feet") may increase the activity of larger muscles upstream and lead to injuries not dissimilar to the example I provided above.
Another consideration is spinal stenosis. Early on in this short career of mine, such a presentation often led to guarded prognoses. However, as I've learned throughout the year utilizing a "DNS mindset", spinal stenosis may simply be thought of as a desperation by the body to utilize structural anatomy to stabilize the spine due to decreased stability and motor control of the core musculature. And spondylolistheses? Well, you can probably guess my answer.
Think about it, the next time a patient presents with a spondylolytic spondylolysthesis, it may be wise to assess and determine whether or not a diastasis recti is present. You're likely to find one. Because rather than a 6 pack being the ideal, my thought process has shifted toward the "belly". And although it may look like some individuals solely possess a 6 pack, if you ask a successful powerlifter to load up under a bar with shirtless (ouch), you’ll probably see that he actually possesses a "belly".
Several questions were asked throughout the weekend about releasing restrictions.
"Shouldn't we release the muscle first if it's adhesed"?
Some might argue "yes" but I've learned to counter with the question, of why is it restricted in the first place? Is it doing the job of something else?
You also may remember the above image. If not, it's a diagram of the "stabilizing system of the spine" by Panjabi and depicts the important 3-way interaction between the nervous system, the musculature and the passive structures. Unfortunately, this 3-way interaction is often forgotten by many practitioners today. Because how often do we solely address the muscles and / or joints, yet forget the important contribution of the neural system?
And as Alena asked,
"How did his ’92 papers not change our treatment philosophy? Why are we still “fixated” on just joints and muscles?"
So we must remember that understanding the functional standpoint of joint centration is respecting the role the CNS plays in control. For more information on this, make sure you take the time to read some of Peter Reeves' work.
During the course Brett Winchester discussed the role of the anterior structures of the core which prompted me to post the following on facebook.
"I think we can be even more precise with our thoughts on the rectus abdominis. We've moved away from flexion to anti-extension. But we can move even further away toward contribution to IAP. If we think about this muscle as a team player then maybe we'll be less confused."
Because in my opinion, very often, the Rectus isn’t for flexion nor is it for anti-extension, it’s for IAP to buttress the spine against erector load.
For those of you that work in the sport setting, yet still have a difficult time comprehending DNS principles, here is a little quote from a recent article about Steven Strasburg.
“To throw a baseball properly, a pitcher must get into the right position at the right time with the right succession of movements, like dominoes falling. Disruptions in this kinetic chain, as experts call it, cause problems at the weakest link, most often the elbow or shoulder.”
Note: Clare Frank goes into more detail on the “whole body approach” in this interview, courtesy of pttalker.com.
“Good diaphragmatic function is like a natural manipulation with every breath”
So as you can see, DNS is about filling the gaps. It's amphoteric nature of every exercise being a test and every test being an exercise certainly widens my continuum of assessment and exercise, effectively deepening my toolshed. It's about facilitating breath where patients lack and engaging muscle activity where inhibited and/or decreased. And for those of you who have learned this approach, you will see why, from a clinical perspective, I believe that very few people need more open kinetic chain training in rehabilitation. We need to spend more time respecting centration and the body's support function just a little bit more.
But most importantly, learning the DNS approach will get you into the habit of asking "why". And as a clinician this should be your primary question.
Because in it's truest sense,
"The definition of “Failed Back Syndrome” is operating on a consequence, not a cause"
With an all-star cast of faculty, organizers and participants, it wouldn't be difficult to say that the DNS program held at Athletes Performance - Arizona may be one of the best opportunities for the professional development of rehabilitation-based clinicians in North America.
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.
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.
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.
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.
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 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"
"Don't be tied to your methods...be tied to your systems and principles".
"It's not about the natural history of pain and injury, it's about the recurrence rate"
Kyle Kiesel on the Functional Movement Screen
Greg Rose & Gray Cook on the Selective Functional Movement Assessment
"Our diagnostics (our thought process and clinical decision making) is just logic"
The Rules of Screening
"It's not magic, it was just a stability problem".
"Never bring a mobility problem to a stability correction...DON'T BE A ROOKIE!"
Kyle Kiesel on Pain and Motor Control
"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!”
SFMA Breakouts 101
Greg Rose on Functional Training
The Functional Continuum
The 4x4 Matrix for Reloading a Stability Problem
4 Functional Positions
4 Functional Exercise Resistances
"Rookies only do 4x4's"
"Isn't it a better idea if I just gave you a philosophy and you make up the exercises?"
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.
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.
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
Flexibility, Yoga Training, and Ergonomic Advice
Functional Performance Training
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.
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
Dynamic Stability Progressions
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.
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.
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:
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.
Having integrated their systems into both athletic and clinical practice over the past several years, I felt it was necessary for me to attend the internship to fully understand the goals of the "system", particularly since one of my objectives is to perform risk identification research here at the University of Alberta in the near future.
While this was certainly a comprehensive internship, my goal here is to provide you with a brief review of my internship experience.
To start off, I will first admit that while I have been using the SFMA for quite some time, there have been many instances where I have "broken the rules". So one of my objectives coming into the internship was to truly understand when breaking such rules is ok and when doing so may be a bad idea. Take for example the treatment-based classification for low back pain. Research has demonstrated that there may be instances where manipulation, stabilization exercises, and other treatment strategies are appropriate for patients presenting with low back pain. Now if you're familiar with the SFMA, you'll understand that often your assessment will lead you to areas away from the region of pain for the purposes of correction and treatment. So taking both of these into account, should we indeed be breaking the rules and adhering to the TBC or should we strictly follow the SFMA. Well based on our discussions during the internship, it basically comes down to this:
"The rules are there to keep you safe when you don't know what you don't know...that ultimately, you just need to know why you got to where you got"
Many of you who FMS trained will know that the FMS is a tool used to aid in predicting injury prior to participation in athletic activities. You will also know that the objective of the FMS is to identify movement pattern dysfunctions that may lead to injury through identifying an athlete's (in)ability to perform 7 specific movements. What you will also know however, is that the FMS has come under intense scrutiny in recent years not only due to a misunderstanding of its role in clinical scenarios, but also due to its use for anything other than its true objective. Specifically, it has been criticized to lack both a measure rotational competency as well as end-range, dynamic stability and as a result, many professionals simply aren't convinced. Ultimately, my goal here is not to change one's mind but simply to introduce the Y Balance Test.
The Y Balance test was covered heavily in this internship and since I was relatively unaware of its role in the overall system, I can honestly say that learning this test has really opened my eyes and mind to the role it plays in the identification of injury risk. Incorporating both an upper and lower quarter component to end-range, dynamic stability testing, this test now occupies a large space in my shed. Through its combination with the original FMS, as well as the software by move2perform, I really and truly think that this system holds a lot of power in identifying an athlete's future risk of injury. To put it simply, the Y Balance Test seems to be an excellent predictor of risk (at least in the current literature) while the Functional Movement Screen tells us why and how. Now combine this with a previous history of injury, the athlete's sport and age and boom...you have an excellent algorithm for risk identification. Oh wait, this already exists with the move2perform software!
One of the highlights of the internship was an evening kettlebell session with Paul Gorman, ATC, RKC, CSCS. As someone who uses kettlebells but has never been formally trained, this was an excellent learning opportunity for me to truly understand its role in the rehabilitation setting. Paul spent plenty of time teaching us methods for progressing the Deadlift, Swing, Turkish Get Up, and Goblet Squat. Specifically, he broke each of these movements down to their component parts and really elaborated on what we should be focusing on when working with our clients and athletes. I can provide you with all the specific details here but I truly believe that formal training is a more responsible form of learning that a simple blog post. What you should note however, is that adherence to proper progressions is the key to kettlebell training. That said, here are some images from this KB session.
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.
Overall, this internship was a success for me as a practitioner at this current stage in my career. Again, my objectives for this course was not only to truly understand the system in its entirety, but also to solidify my understanding of patient management based on my current knowledge of the existing research as relates specifically to the functional movement system as well as sport medicine in general. Most certainly, one can hold a successful practice without ever taking any of these courses, however, for me, any opportunity to further myself as a clinician is just icing on the cake.
If you're interested in specific details of information that really resonated with me over the week or simply want more information of any component of the functional movement system, you're more than welcome to use the comments section below.