Dynamic Neuromuscular Stabilization as the Missing Link?

Back in November, through Craig Liebenson and others in the Prague School clique, Pavel Kolar presented 2 separate courses in the Phoenix area. The first one was a condensed overview with an athletic focus at AP, and the second was the level A course in the Prague School certification process. I took the level A. Coach Boyle, Eric Cressey, the DBacks crew and many others were at the overview course, and I have seen the manual. But not having been there, I don’t know much about the specific talks over the slides. Recently John D’Amico was at a huge program in Naples where Kolar and Dr. McGill were the keynote speakers. And Joe Heiler is currently at the same Level A that I took in Los Angeles as I type this.

As I told John D., what the Prague School is doing has long been pushed by Janda and Lewitt with the new twist of Reflex Stimulation that was brought in from the influence of another pediatric neurologist (same as Janda), Dr. Vaclav Vojta. I think this program is going to be the next big thing in training and rehab, and my affinity towards it is very cemented by the shared foundations for especially Gray and Kyle’s work, but also Sahrmann, Mulligan, and the Queensland crowd.

Recently when folks ask me what books I am reading or have in my quueue, I’ve said I’ve gotten away from performance-based texts. What I mean is I’m not reading as much of things like Supertraining, Charlie Francis, or the European periodized approaches as I did a few years ago. I’m sure this is partly because I am doing more rehab now than I did in the NBA. But I think refining my extension of Gray’s work, I’ve come to think that program design and special exercise selection, which crucial in many ways, is far less important than fine tuning the body through its efficiencies in motor control and movement organization. I think then and only then, can you make a real monster.

So there’s specific technique that is limited by force production and rate of force development. You can teach all the little double leg exchanges and set up as many cones to run around, but in the end agility is graded by how strong you are and how fast you can express your strength. But beyond that, force and speed, which have no ceiling, also have a governor on them, which is the harness we have on delivering elite movement and control of our body. That too can be maximized, so it still always goes back to bigger, faster, stronger, but I am not so sure we even have a fraction of a handle on maximizing mobility and stability, and the foundation of pediatric-biomechanic/orthopedic-neurological mastery.

Now don’t get it twisted. This morning I had 275 + greens on the Buffalo Bar for 10 sets of 2 and then pulled 315 for doubles on speed day. That stuff isn’t being thrown away, but my point in establishing this balance was really the key take away from Kolar’s course. The name of Kolar’s system is DNS – Dynamic Neuromuscular Stabilization. Kolar is a PT in Prague. Like I said, he is a disciple of Janda, Lewit, Vaclav, among others, and like any true brilliant, he takes their combined work to another level.

Just like the FMS and SFMA, the key to the DNS system is less about the tools that you use to achieve the indicators of success and more about the indicators themselves. So it is a thought process and system more than a specific evaluation, assessment, and training paradigm. You can spread peanut butter on somebody if it gets you what you want AND keeps it that way. You just be at the top of the food chain in knowing and prioritizing what you want.

1. The fathers of this system were pediatric-trained, so the neurodevelopmental model/developmental kinesiology that many know from the FMS and SFMA prevails. I’m sure with more repetition, the benchmarks and milestones of months 1-14 will be memorized and second nature. This isn’t particularly evidence-based or really even science-based. But for me, it does make common sense. The sense of it is that there is something inherently right about expecting adults to own primitive patterns simply because when we first learned and mastered the primitive patterns, no one taught them to us. They were already in our brains.

There’s got to be something right about using those movement extrapolations if “come inside the box” when we start life. I’ve enjoyed turning some anti-FMS folks on to the program when describing the FMS of course with physical demonstration like this: baby is on their back, and they play with their hands and feet (ASLR/SM). Then they roll (RS). Then they push up to their hands (TSPU). Then they walk their hands to their feet and wind up in squat (DS). Then they take big giant steps with their arms all flailing (HS). Lastly they fall and try to catch themselves (ILL).

The key before establishing the assessment process for DNS is respecting that if certain movements are not mastered within the positions that correlate to year 1 milestones, you are not all the beast you can be. Can you earn these milestones just by good training. Yes, I think you can…..for most of DNS, not all. Coach Boyle proved that about 5-7 years ago when he FMS’d his athletes without it as an original indicator. However, there is more to DNS than just primitive movement patterns.

2. The name of the assessment and training approach in DNS is the Integrated Spinal Stabilizing System (ISSS). The ultimate goal of ISSS is for the brain is properly sequence joint position and spinal stability through intra-abdominal pressure (IAP). The specific tests are things we’ve seen from Janda and Lewitt and look for appropriate sequencing of tonic and phasic muscles.

Why IAP? Because IAP is established in optimal breathing. What’s the first thing baby does before playing playing with arms and legs? Breathe. And breathing in healthy babies has been shown in adults to provide appropriate core activation.

3. Appropriate core activation takes us to the next point hallmark of DNS and ISSS. What does core activation mean? What is this stabilizing system? This system includes the deep neck flexors, multifidus, diaphragm, abdominal wall/transverse abdominus, and the pelvic floor. I don’t think too many folks are attentive to all of these factors in our training. I know I wasn’t.

So there’s been much discord on the value of transverse abdominus. McGill still reigns supreme even though he message is often garbled I think many folks don’t appreciate that he’s right, and they’re wrong. TvA isn’t the key to establishing a strong core or IAP. Draw-in is still useless in my book. The master of activating all of these muscle groups, which Gray and Kyle call the Inner Core, is breathing. When the diaphragm activates properly, that’s where the feed forward mechanism that Hodges et al talk about.

It’s like you jump our of an airplane, and the parachute opens. The top of the chute goes first, and that’s the diaphragm. Then the slack is taken up in the harness, and there’s a quick yank. That’s the pelvic floor. That’s why some folks have great success with kegels for back pain because they are yanking down on the parachute first. Problem is they don’t access the parachute all the time. The feed forward mechanism brings in the multifidus and TvA by default. The little tiny parachute on top of the big parachute is the deep neck flexors. This is one big giant breath. Baby could never develop appropriately without these core muscles on first. And baby couldn’t do that without big belly breathing.

You don’t own movement unless you can breathe at the pinnacle of the movement, when max mobility and/or stability are needed. McGill talks about breathing over a brace. Get out into bird dog or toe touch or the bottom of a push up and hold it and try to kill diaphragmatic breaths. That is owning movement according to DNS.

Lastly here, getting back to Hodges et al, all they ever said was these muscles had a delayed onset for folks with back pain. If you breath and train breathing properly, the brain never shuts them off. I’m sure never isn’t the best choice of words there, but that is how IAP, the inner core, and breathing tie together. I think this is how sometimes we see athletes that are not very built but are really strong. You see this a lot in the Eastern training approaches like martial arts or clubbells, etc.

4. Now to the magic. I said before I think great training can yield good mastery of most of the ISSS even if you are not using it as an objective template. What you can not train for traditionally are “anticipatory patterns.”

Earlier I said that primitive movements are all pre-programmed in our brains at birth. These movements are in there. They’re cataloged. I think this is why Gray’s methods work. As we return the mobility/stability continuum closer to what it was as an infant, this catalog of correct stabilization patterns is accessed.

Kolar’s integration of Vaclav’s work is through Reflex Stimulation. As babies transition to milestones, they require a “point of stability,” almost something to push off of to change position. For those that have little ones at home, they will see that this point of stability is bone. This force into bone causes morphological changes in the bone changing its orientation. For instance certain angles of the ribs that are posteriorly oriented in adults and anterior in infants. There is almost no femoral neck in babies. Poor development potentially causes anteversion or retroversion. Vaclav’s hypothesis was that it is this stimulation of bony changes that was the automatic starter for movement transitions. And in normal babies, there is always a standard for what “good” movement looks like.

So Reflex Stimulation is putting the body into a primitive pattern. There are several in the training approach and applying vectored pressure at certain zones in the body. These zones immediately correlate to where baby gets a point of stability in development. The magic, which DOES NOT work for everybody, is that pressure at these zones causes the person to go through primitive movement without them controlling it.

I know. I wouldn’t believe it either if I hadn’t seen it myself. Remember, not everybody is responsive to demonstrate these anticipatory patterns. The first goal is to help normalize breathing, which resets the inner core, which then allows you to get into more traditional core training. I swear to you that I was playing my good friend, Jeff Banaszek, who is on the TPI Board, like a fiddle by pushing on his ASIS. It was like a joystick to his hand and arm. I push up right, his hand went right. I let go of his ASIS, his hand flopped.

The value here is 2 fold. First, you have an ultimate reset button to normalize the system for efficient rehab when more traditional things don’t work. But secondly, getting back to making monsters, sometimes the anticipatory pattern is wrong. Kolar would consider this a severe movement dysfunction and require correction. This is the angle that I don’t think great training can access without looking for it. This is what Kolar says.

I can appreciate that most of us can not go through what is necessary to check anticipatory patterns. But I do think it is valuable to know that there is so much underneath even ahead of the curve training and rehab approaches.

5. Level A did not get into all of the RS positions or much exercise. The focus of the exercise is to use breathing to gain joint centration. I mentioned Sahrmann earlier. Sahrmann speaks about a principle called PICR, Path of Instantaneous Center of Rotation. It’s the same thing as centration. It is about establishing the perfect measure of balance on all sides of a joint, which is what Janda would suggest as phasic muscles and tonic muscles, which is what Gray and Kyle would call a high threshold strategy. It’s just the right joints being in the right place to do the right thing at the right time. It’s really all what we are trying to do anyway, right?

My exposure to DNS doesn’t include a wealth of “exercises.” The most concentric approach is to get into the ISSS positions supported (legs under a box instead of held up) and work the breathing patterns.

The inner core will trigger in 2 ways, extreme mobility and respiration. Respiration is guaranteed, extreme mobility (rolling, yoga) is less reliable.
The key to either of these strategies is that the end result is an aggregate activation pattern, not any particular muscle in isolate.

Consider some of these notions.

TvA is a critical player. However, the draw-in strategy is completely worthless. Whoever it was as it was not Hodges et al that determined that the draw-in had a high EMG of TvA terribly misguided many of us. Activation of TvA in a draw-in pattern does not increased intrabdominal pressure, so the other components of the inner core are not triggered.

So when foolish pilates instructors teach the draw-in, I think some people actually get better not from the draw-in triggering inner core, but the graded mobility of the arms and legs triggering the inner core.

Johnson’s Multifidus Solution suggests the top 3 EMG multifidus exercises are prone leg extension, quadruped straight leg extension, and standing draw-in. Again, EMG misleads as the sequencing of these muscles does not guarantee IAP.

I think there is more efficacy to the pelvic floor musculature in isolate in that it appears that engaging the pelvic floor is less of an exercise and more of a movement trigger. Try breathing while holding your pee. Very difficult to breath apically.

Out of the 4 lower inner core muscles, only the diaphragm guarantees IAP. If you turn on diaphragm with respiration, you will get the other 3 to turn on.

So how to you program the breathing?
Aside from HEP and constant cuing, we get breaths during any stretch, any passive soft tissue work. How long do I hold this plank? As long as it takes to get 20 breaths? How long to stay in the top of the bridge? As long as it takes to get 3 breaths.

The breath always has to take place at the end or most challenging part of the maneuver. Go back to the SFMA or FMS and try to get a breath at the apex of each move. You may see some changes in how you would score the move. Look at breath in symmetry as well. You don’t own SLS until you can bury a breath on each leg.

The neck is a little different as it is somewhat detracked by the t-spine. Lots of rib dysfunction can limit the IAP of the bubble’s reaches. There are not a lot of movements you can do with the neck in isolate. There are neck planks and AA nodding, and both of these can be done in varied positions.

However, keeping the neck in the lower cervical extended and upper cervical flexed position in EVERY single exercise is paramount. NEVER EVER look up in the squat. Your eyes can and should look up, but not the neck. Never look up in a pushup. Always drive the neck straight backwards as if laser beams were pushing your eyes straight back into your head. The neck should feel pressurized. Lower half strength and power will go through the roof, and you will be honoring ISSS.

  • Rolling, we will do in sets of 3-8. No real rhyme or reason.
  • Consider either arm rolling in terms of correcting SM.
  • Consider supine to prone rolling in correcting MSF.
  • Consider prone to supine rolling in correcting MSE.
  • One may be excellent, while the other is miserable. Do not go to prone to supine rolling without a fair amount of prone hip extension. Inner core won’t respond without extreme mobility.
  • Obviously all of the rolling patterns address MSR.

Once you master rolling on command, we’re typically done with it. Maybe we will go back to check it every once in a while, or if there is a regression after an event or heavy activity. Keep in mind in trying to hash through programming the inner core is that it just need to turn on in sequence. It doesn’t need to get better at that. Once you have it, you’re good. But going through corrective and more terminal and properly loaded movements that honor mobility, the stability will be reflexive and natural. It doesn’t need to be considered in terms of sets and reps.

To program inner core…………..

1. Manual Therapy to remediate pain
2. Breathing in the ISSS positions
3. Breathing in all mobility or stability poses
4. Always keep the neck in line with the spine

  • March 30, 2010

Leave a Reply 9 comments

Mike T Nelson Reply

Very interesting and thanks for taking the time to write up such a detailed article for those that could not make the talks.

Thank God someone else is telling people not to look up during a squat and other exercises. Yeah!!

Question (2 of them)

Perhaps I got this wrong, but would you say that for most exercises, breathing should be anatomically matched to the exercise (as lung field is compressed, exhale; as it expands, inhale)?

Further more, once you can not keep a non altered breathing pattern, you should terminate that exercise set?

Thanks in advance for your time
Mike T Nelson PhD(c)

Charlie Reply

1. The appropriate stereotype for inhalation is a downward motion of the ribs along with a rounding of the entire visceral/abdominal region forward and outward. Exhalation is a return to the resting position.
Obviously this is tempered with fatigue.

2. If you can not bury a perfect breath on command at any part of the lift, I think that is a very strong argument to not be performing that lift or movement. I am not quite there yet with that level of strictness, but I am a lot closer when we are in a corrective exercise mode than a strength or power training motion.

Mike T Nelson Reply

Thanks for the follow up and your time – much appreciated Doc!

What are your training results after being more strict with breathing under load?

rock on!
Mike T Nelson PhD(c)

Charlie Reply

Very difficult to determine since we do so many things we think are “good,” when we train. With 11 years of experience, I don’t think I’m anywhere near the stage of fine tuning.

craigliebensondc@gmail.com Reply

Charlie,
One tweak.
The appropriate stereotype for inhalation is 360 deg. horizontal – not vertical – motion in the thoracic cage/abdominal region. I would not say downward, but I would say verticalization is the most common error. And, of course rounding rather than drawing in.

Lewit said “respiration is the most important movement pattern.” It seems obvious, but it is usually ignored in training!
Craig

kinoki foot pads Reply

Not all the time can you discover a well written piece that sticks to your head for some time. I have to say your work has kept my mind working for days. Keep on moving minds!

Jeffrey Linder Reply

Thank you for taking the time to write such a well planned, well organized article. I am a chiropractor in NYC and am interested in taking my FMS training further. Your article helped. Thank you.

Larry Knapp Reply

I agree with the comments above! Thank you for writing such an awesome piece. Your material always inspires me to keep continuing my education in this field.

I have a quick question if you have time:

“baby is on their back, and they play with their hands and feet (ASLR/SM). Then they roll (RS). Then they push up to their hands (TSPU). Then they walk their hands to their feet and wind up in squat (DS). Then they take big giant steps with their arms all flailing (HS). Lastly they fall and try to catch themselves (ILL).”

Did you put these in order of how you would correct or just put them out for the description?

I thought correctives needed to go SM, ASLR, RS, TSPU, ILL, HS, DS? Is this correct?

Larry Knapp Reply

That’s what I thought. Thanks again!

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