DNS Exercise I

www.rehabps.com

07.04.15

Who Is the Founder of DNS? Professor Pavel Kolar, PaedDr. Director Rehabilitation Rehabilitation Clinic 2nd Medical Faculty Charles University Prague, Czech Republic

www.rehabps.com

Kolar’s Approach to Dynamic Neuromuscular Stabilization !"#$%#&%'()% Sport and Fitness handouts: +#&" , Rehabilitation Clinic University Hospital Motol Charles University Prague, Czech Republic

Physiotherapist by training who holds a doctorate in pediatrics and physiology •

•

Professor of physiology

Head clinician for the Czech Olympic teams  – soccer, soccer, ice hockey, hockey, tennis. tennis. •

Sport

What is DNS? •

•

Concept of  DNS  DNS is based on the on the scientific principles of developmental kinesiology (DK) i.e., (DK) i.e., the neurophysiological aspects of the maturing locomotor system. It includes both, knowledge and a theoretical base, in addition to assessment, treatment, exercise and functional strategies.

Dynamic Neuromuscular Stabilization

•

Sports performance

! Level of physical condition

- Power/strength/speed - Endurance ! Sport technique

- Optimal postural foundation - Movement quality/coordination - Movement awareness

1

www.rehabps.com

07.04.15

Sport Loading Movements with maximum muscle power

•

Increased demands on muscular coordination

•

Maximum range of motion Maximum loading on ligaments and tendons Increased respiratory demands

•

•

•

Training •

•

•

 Adequate amount amount of load to evoke body body adaptation  Adequate loading loading time and repetition Neuromuscular Neuromuscular adaptation

- Cortical control – process of motor learning (slow movements) - Motor programs – learned and fixed programs (cerebellum, basal ganglia pathways) •

Biochemical and morphological adaptation

40"., 5+)367"8

Training Posture •

•

Should respect anatomy and physiology of the body (local, regional and global anatomical parameters) Neutral joint position during the entire course of movement

-

./" )0#1"23 %)4$)% 5&6)77)&8 +'22#")98 :2)0#$%)&;;; :2)0#$%)&;;; /9"?&); !"#"$%  '$@/&A#B/$ %)4$)9 '%)#2 >/9"?&) C &'()*+,+-*%., 0"1",+&2"#3

- How to define neutral joint position? - Why is it necessary?

Dynamic Neuromuscular Stabilization

2

www.rehabps.com

07.04.15

Development of Postural Function Postural function - Dynamic function - Precedes and follows every movement •

Postural Foundation Definition of ideal posture - Foundation of neutral position – established during motor development •

- Ensures position of the trunk, spine and pelvis during movement - Universal pattern that stabilizes any movement – controlled on subcortical level

- Neutral joint positions "

enables optimal loading

- Its quality depends on quality of motor development during early childhood

"

ideal balance between agonists and antagonists

"

ideal interplay with other muscles and segments in the whole system

Neutral (Centrated) Joint Positions

Functional Joint Centration •

•

•

Dynamic neuromuscular strategy that leads to optimal joint position that allows for t he most effective mechanical advantage  A centrated joint has the greatest interosseous interosseous contact to allow for optimal load t ransference across the joint and along the kinetic chain.  Allows for maximal muscle muscle pull and protection of of passive structures

Optimal development – in any position, all the  joints are functionally functionally centrated! centrated!

Dynamic Neuromuscular Stabilization

3

www.rehabps.com

07.04.15

Functional joint centration = Neutral joint position •

•

•

•

Normal (CNS) Development

Enables generation fo maximum muscle power Improves sport performance Ideal/balanced joint loading- decreased load on ligaments and tendons, prevents cartilage overuse and degeneration

Newborn

3 m/o healthy infant

May prevent repetitive strain injury

Normal Muscle Function, Normal Posture 5 months

8 months

9 months

12 months

10 months

Dynamic Neuromuscular Stabilization

Program CNS

  Function Muscle

!

!

Structural maturation Bone (joint)

4

www.rehabps.com

07.04.15

Developmental Kinesiology 1st phase

0 – 4 months

sagittal stabilization matures

What Causes Spine and Torso Stability? •

•

Intra-abdominal pressure (IAP) is the main stabilizer of the spine – this pressure is applied against the abdominal wall and the dorsal-lumbar fascia and supports it. IAP results from ballanced coactivity of the diaphragm and trunk and pelvic muscles.

Stabilization in a Sagittal Plane Optimal pattern of core stabilization in 3 m/o infant and in a weight lifter Same muscle coordination; weight lifter just needs more strength; joint centration same in both

Trunk Stabilization Liquid ball phenomenon

INTRA – ABDOMINAL PRESSURE (IAP) REGULATION Via balanced coordination between the diaphragm, pelvic floor and abdominal muscles

Dynamic Neuromuscular Stabilization

5

www.rehabps.com

07.04.15

The diaphragm: 3 functions

Respiration

- Respiration - Stabilization - Sphincter

•

•

Breathing and stability functions are always co-dependent. Developmentally important – future stability

.#.3+2*%.,,( 7",.3"0 3+ 37.#)1"7)6) .90 D

Muscle Activity during Ventilation

Dual Activity of Diaphragm

Muscles of Quiet Inspiration ! Diaphragm

1. Lowering and flattening of the dome, increased diameter of vertical thorax 2. Increased IAP results from diaphragmatic descend; diaphragm expands the lower ribs laterally. 3. Once stabilized by an increased IAP, continuing contraction of the costal fibers elevates the middle and lower ribs (Neumann, 2002).

Dynamic Neuromuscular Stabilization

•

Established during ontogenesis (6 months)

•

Respiratory

•

Postural

- contraction and flattening of the D prior to any movement - Cause active response of abdominal and pelvic floor muscles – ventral spinal stabilization

6

www.rehabps.com

07.04.15

Ideal Respiratory Pattern

Rib Movement during Respiration

! Initial

position – relationship between chest and spine ! Upper ribs – rotation in CV  joint - chest expansion in ventral direction ! Lower ribs – rotation in CV  joint causes expansion in lateral direction ! Sternum is stable ! Movement occurs at SC joint – if inadequate, AC joint movement substitutes

Ideal Respiratory Pattern ! Must

be maintained during any dynamic functional activities and exercises ! Spinal stability results ! Competition between postural and respiratory function of the diaphragm - affects the quality of phasic movement ! For example: a tennis player w/weak stabilization -Unable to maintain postural diaphragmatic function while playing ! Yoga trainers usually train abdominal breathing (ventral protrusion only!) and forget to include the lateral expansion

Dynamic Neuromuscular Stabilization

“If breathing it is not normalized – no other movement pattern can be.” Karel Lewit

7

www.rehabps.com

07.04.15

Respiration and Exercises •

•

•

:3.9*,*;.$+# ?76#@ AB3"#)*+# ?")3

•

•

•

•

•

Dynamic Neuromuscular Stabilization

Insufficiency of the deep neck flexors: c o-activation with extensors C spine hypermobility, (head extension) Hyperactivity of auxiliary respiratory muscles Upper scapular stabilizers & short neck extensors hyperactive Insufficient lower scapular stabilizers

20

www.rehabps.com

07.04.15

Extension Test: insufficient pattern o

o

The upper angles of the shoulder blades are pulled in a cranial direction (activity of the upper and middle trapezius), adduction of the upper angles  Abduction of the lower angles

7. Quadruped Rock Forward Performance " The patient slightly shifts the head and the trunk forward (rock forward) Assessment " Hand support " Position of the scapulae

Quadruped Rock Forward Evaluate: •

• •

•

Support on palms (tripod) Scapular stability Symmetry of T/L paraspinals Hypertonus of upper stabilizers ?

Wrong stereotype: Hypothenar hand support (ulnar side of hand) Scapular “winging” (cranial and lateral directions) Hypertonus of PV T/L and upper stabilizers = elevation of the lower leg • • •

Dynamic Neuromuscular Stabilization

Kapandji, 1974

21

www.rehabps.com

07.04.15

8. The Bear Position •

• •

•

NO $

• •

•

Higher & more challenging position Mistakes are more pronounced Watch the position for centration of the ankles and the knees Position of the pelvis, L spine Position of the scapulae  Activation of the laterodorsal parts of the abdominals Neck centration, head position

 YES %

The Squat test

9. The Squat test •

•

•

•

•

•

•

Dynamic Neuromuscular Stabilization

Neutral pelvic position Good activation of the laterodorsal sections of the abdominals and posterior diaphragm Lumbar spine centration – neither lordosis nor kyphosis Centration of the hip, knee and ankle  joints Correct position of the shoulder blades - ABD & slight external rotation Shld, hip and foot should be in 1 line Medial knee should line up between 2nd & 3rd toes

Correct pattern

22

www.rehabps.com

07.04.15

The Squat Test – Modified

The Squat test Poor stereotype •

•

•

•

•

Hyperactivity of the paraspinal muscles (T/L region)  Anterior pelvic tilt Decentration of the hip, knee or ankle joint Shoulder elevation, protraction Head in forward drawn position

•

•

•

If squat with no support is too challenging Use this modification Modification for both, assessment and training

DNS Assessment •

•

Respiration pattern – test diaphragm in different positions, during loading, during sport Evaluate and analyse sport technique or movement

-  joint centration and torso/pelvis axes during the movement •

Dynamic Neuromuscular Stabilization

choose 2-3 DNS test - indentify insufficient or incorrect motor patterns

23

www.rehabps.com

07.04.15

Exercise in Sport and Fitness Based on DNS Principles

Sport Technique Evaluation •

•

•

•

Videotape athlete during sport activity Pay attention to joint centration and movement pattern characteristics Notice any incoordination,  jerky movement, coupled movement Look for the quality of relaxation!

DNS Exercise Principles

DNS Exercise Principles •

Correct respiration

•

Optimal sagittal stabilization

•

•

 All joints and segments in neutral (centrated) positions

•

•

Establish a good quality of support

•

Dynamic Neuromuscular Stabilization

Number of repetitions – depends on stabilization Exercise only as long as the neutral position and good quality of movement are achieved and maintained Exercise in static positions - improve segmental stabilization function

24

www.rehabps.com

07.04.15

What Position and Load to Start with? •

•

•

Start in posturally easier (lower) positions (developmentally younger) Exercise must activate optimal motor patterns (stabilization, support, stepping forward)

DNS Principles in Athletes DNS based training a) respect ideal posture as defined by developmental kinesiology b) Train variability - adaptation to sport loading c) Cortical function training– improve sensory integration

Reduce the load if abnormal position in any segment occurs

Preparatory Exercise with Load Chest positioni ng

IAP proper activation

Supine with Exercise Ball 1) Patient supine, legs flexed 2) Push one hand and contralateral thigh

against the exercise ball

Mistakes: • •

•

•

 Assist with neutral position of the rib cage and costal expansion during inspiration

Dynamic Neuromuscular Stabilization

Ball til ts laterally The patient elevates shoulders Increased L lordosis Patient holds her breath

Teach client how to breathe and regulate IAP, to activate “abdominal cylinder” prior to any movement of the limbs

25

www.rehabps.com

07.04.15

Exercises in Supine

“90-90 Supine“ with T-band

•

•

•

The T-band is wrapped around the shins (just below the knees), crossed from the front to the back side, and brought forward around the thighs (just above the knees), and held in the palms (wrapped twice) with the free end of the T-band placed between the thumb and index finger. Elbows are flexed 90 degrees.

Maintain the basic supine position with the head, spine, trunk and pelvis in a neutral position, breathe into the area above the groin. Supinate your hands while performing external rotation at shoulders.

•

•

Exercises in Supine

Supine “90-90 position” Neutral = caudal position of the ribcage during both, exhalation and inhalation Hold hands, palms facing up Extend your elbows as if performing a bench press Use loads for exercise progression

Exercise in Supine with Pulleys Set up position: supine with legs 90-90 and sagittal stabilization

•

•

•

Supine “90-90 position” Hold weights, bend elbows and shoulders while maintaining caudal position of the chest, neutral position of the spine and pelvis Extend elbows as in a triceps curl

Dynamic Neuromuscular Stabilization

•

•

Posterior delt, ER, triceps, obliques One arm - from 90°flexion pulls into abduction against pulley resistance

• •

•

 Anterior delt, pecs, obligues Supporting arm is in 90 degre abduction Stepping forward hand with pulley in flexion, ER and ABD pulls to adduction

26

www.rehabps.com

07.04.15

Exercise in Prone •

•

Prone position, elbow support Increase intra-abdominal pressure and load the symphysis (without activity of the glutes).

•

•

•

Depress the shoulder blades while keeping them apart Lift your head from mid thoracic spine and with the C spine straight. 3-6 reps with maximum quality

Quadruped Exercise Basic position

Horizontal abduction with load

Low Kneeling Exercise •

•

•

•

•

•

Sit on your heels Knee distance = shoulder distance Elbow support, forearms pronated Stabilize the shoulders! Cue the client to lift his head with C spine straight Guide the T spine and L spine straightening while patient is lifting from his heels

Quadruped Modification •

•

• • •

•

Centrated quadruped position Spine straight! Knees distance = hands distance hips in 90°, shins and feet converge.

•

•

•

Dynamic Neuromuscular Stabilization

Use pulley or weight to move one arm Joint centration throughout the entire ROM Direction of moving arm can vary

Centrated quadruped position Slide one knee back and forward while maintaining the pelvis horizontal and spine straight

27

www.rehabps.com

07.04.15

Quadruped Modification •

•

•

•

Contralateral arm and leg support Supporting knee is placed in front Spine, pelvis, rib cage, shoulders and supported hand well centrated at all times! Stepping forward arm moves against pulley from extension with IR to FL with ER

Sitting Exercise Proper IAP prior to load

First, obtain well balanced IAP & “abdominal cylinder” during: a) respiration b) exercise

Arm press with optimal IAP and centrated pelvis

Place legs on the bench in 90-90 position Knee distance = shld dist. Balanced IAP first and then arm press

3M: PRONE Developmental Positions 3 – 13 months SUMMARY

Dynamic Neuromuscular Stabilization

28

www.rehabps.com

07.04.15

3M: SUPINE

4M: SUPINE

5M: PRONE

5M: SUPINE

Dynamic Neuromuscular Stabilization

29

www.rehabps.com

5M:SIDE - LYING

6M:PRONE

Dynamic Neuromuscular Stabilization

07.04.15

6M: SUPINE

7M: PRONE

30

www.rehabps.com

07.04.15

7M: QUADRUPED

8M: SIDE SITTING - HAND SUPPORT

Dynamic Neuromuscular Stabilization

7M: SIDE SITTING - FOREARM SUPPORT

9M: CRAWLING

31

www.rehabps.com

07.04.15

10M:TRIPOD

10M:ROTATION

Dynamic Neuromuscular Stabilization

10M: SITTING

11M: BEAR

32

www.rehabps.com

11M: KNEELING

12M: DEEP SQUAT

Dynamic Neuromuscular Stabilization

07.04.15

12M: SQUAT

13M: VERTICALIZATION

33