The Monday Memo
August 6, 2018 PITT DPT STUDENTS
Dynamic Neuromuscular Stabilization: A Brief Overview
What is DNS?
Dynamic Neuromuscular Stabilization (DNS) is an approach to facilitating appropriate core coordination that enables our patients to appropriately activate their core for optimal function. DNS is based upon principles of early childhood development that follow pre-determined, predictable patterns. These CNS movement patterns progress naturally as an infant learns to control its posture against gravity, roll, creep, and eventually stand and walk. The concept of an efficient kinetic chain – requiring adequate trunk coordination – is imperative for sport-specific tasks as well as activities of daily living. The DNS approach seeks to address inefficient motor synergies and re-train the CNS to promote optimal function. Per Panjabi’s model of spinal stability, there is an interaction between neural, active, and passive elements to promote spinal stability and allow for optimal function. Treating core strength or passive elements alone is not enough to address these stability deficits. The DNS approach can be useful in addressing the neural element for patients suffering from chronic, recurrent low-back pain (LBP), those we often think of as a “stability” patient.
How can we Apply DNS?
There are several positions in which we can encourage stability. It is important to account for weight-bearing and non-weight-bearing positions. There are a few principles to keep in mind when guiding patient treatment:
- Restore respiratory pattern and abdominal stiffness (See Brooks Kenderine’s article on abdominal stiffness vs. hollowing)
- Establish quality support to allow movement of the extremities
- Ensure joint centration throughout the movement
Our interventions should be scaled with these in mind, and the patient’s ability to perform well in low-level developmental positions will indicate the addition of external resistance or advancement to the next position. Let’s look at some simple progressions:
Supine Dead Bug:
- Unilateral or Bilateral 90/90 Isometric Hold
- Cue patient to activate core to resist increased anterior pelvic tilt/lumbar lordosis as they bring one or both legs to 90/90 position of hip and knee flexion.
- This is a great way to get the patient comfortable with diaphragmatic breathing and maintaining abdominal stiffness.
- Unilateral UE/LE March with Straight Leg Raise
- The patient will maintain 90/90 position with one leg, while alternating UE/LE extension and flexion.
- Regression: Keep the leg in hook-lying position and perform UE/LE taps with SLR.
- Alternating UE/LE March:
- Emphasize slow and controlled tempo, and maintaining good diaphragmatic breathing.
- Isometric Physioball Hold
- The patient will squeeze physio ball between opposite UE/LE and hold, then switch.
- Isometric Hold
- Ensure patient maintains chin retraction, good scapular positioning, and neutral spine.
- Alternating LE Raise and Hold
- The patient will raise and hold one foot, while maintaining chin retraction and neutral spine.
- Alternating Bear Steps
- The patient will step forward with opposite UE/LE, and then backward, alternating side to side.
-Joe Dietrich, SPT, ATC
Disclaimer: These are merely some of the movements described within the DNS system. The principles of appropriate spinal alignment and breathing techniques should be utilized across the board when prescribing therapeutic exercises to our patients.
Frank, C., Kobesova, A., & Kolar, P. (2013). DYNAMIC NEUROMUSCULAR STABILIZATION & SPORTS REHABILITATION. International Journal of Sports Physical Therapy, 8(1), 62–73.
The Monday Memo
August 6, 2018 PITT DPT STUDENTS
Do you know how to Yo-yo?
Oddly enough, the “Yo-yo test,” will be able to help gauge how an athlete can perform in endurance sports. Now, I am not talking about the toy that is tethered to a string around your finger, but a grueling endurance test that is commonly used in high-level athletics. The Yo-yo intermittent recovery test, or also known as the Beep Test, is commonly used for high endurance sports such as basketball and soccer. In short, the test is described in the literature as:
“ …consisted of 20 m shuttle runs performed at increasing velocities with 10 s of active recovery between runs until exhaustion…”
However, we recently used this test for the Pittsburgh Steelwheeler athletes who we have been working with for the past few weeks. The test has been modified for wheelchair basketball and is described as follows:
“Due to the differences between running and propelling the wheelchair, the distance covered in the shuttle run was reduced to 10 m. Pushing speeds were dictated in the form of audio cues broadcast by a pre-programmed computer. The test was considered to have ended when the participant failed twice to reach the front line in time (objective evaluation) or felt unable to cover another shuttle at the dictated speed (subjective evaluation).”
This test has been showed to be important for recording athlete endurance and can be an effective measurement for improvement. The test was administered by a fellow 2nd year, Christie Chiesa, and can be viewed on our Instagram page: @pittsteelwheelers. We had four athletes participate, and they all had an amazing first performance. We hope to be able to use the results as motivation and performance benchmarks for the athletes.
-Jim Tersak, SPT, CSCS
The Monday Memo
July 2, 2018 PITT DPT STUDENTS
The APTA’s “Guiding Principles to Achieve the Vision” which supports the APTA’s “Vision Statement for Physical Therapy” highlights the importance of one of the many roles of physical therapists: promoters of health and wellness:
“Movement is a key to optimal living and quality of life for all people that extends beyond health to every person’s ability to participate in and contribute to society. The complex needs of society, such as those resulting from a sedentary lifestyle, beckon for the physical therapy profession to engage with consumers to reduce preventable health care costs and overcome barriers to participation in society to ensure the successful existence of society far into the future.”
As much as treating impairments is a duty of physical therapists, such is contributing to society by encouraging active lifestyles. Having these conversations (not lectures) with patients contributes to the overall health of our patients but also, as we know, helps to reduce health care costs in the long term. Every patient will reach the end of their journey with physical therapy, and will no longer have a skilled need. It would be easy to say goodbye and never worry about those patients again. However, it is our responsibility to educate our patients on the importance of activity outside of a therapeutic realm.
We have the luxury of getting to know our patients on a more personal level, learning their interests and lifestyles. With the combination of knowledge of the individual and knowledge of the surrounding community, we can become excellent auxiliaries and resources. With an individualized approach, we can urge the use and importance of local community resources. This can be as simple as providing information about nearby parks, upcoming city events such as walks or races, or local gym facilities. There are often facilities or local gyms that have adaptive programs for both children and adults.
Often, physical therapists can be the primary source of information to help patients become more aware of their local communities and the opportunities it presents. Not only should this be a conversation at discharge, but an educational component throughout the entire course of treatment. Emerge yourself in the community and encourage your patients to do so as well!
The Monday Memo
July 9, 2018 PITT DPT STUDENTS
Side Plank Basics
The Influence of Gravity
The classic Side Plank is a fantastic exercise and you shouldn’t just take my word for it! It has been researched countless times and top researchers, clinicians, & coaches swear by this lateral chain exercise for developing stable trunks all over the world!
Without diving into the anatomy, I want to touch on an important concept that can be applied to the Side Plank. That is, using the influence of GRAVITY to progress. In all things movement, our central nervous system recruits muscle fibers to contract & propel our body weight (plus external resistance) against gravity. How we orient our center of mass and direct our movement in relation to Earth’s gravitational pull will play a significant influence on the difficulty of an exercise and the tissue stressed.
This concept is a basic principle that all therapists and coaches who be wise to keep in mind. Understanding the influence of gravity and its effect on the human body is helpful in allowing practitioners to critically analyze a situation and choose a proper exercise strategy that meets its demands. With a static exercise like the Side Plank, it’s extremely easy to visualize this concept and find ways to manipulate gravity in order to achieve a training effect.
Take a look at today’s video to find out how!
The Monday Memo
July 2, 2018 PITT DPT STUDENTS
Teaching the Hip Hinge:
Dowel Rod Hinge Mechanics
As an avid reader of the University of Pittsburgh’s Monday Memo, you likely understand the importance of mastering a proper hip hinge. A proper hinge is demonstrated when the subject bends primarily at the hips, recruiting the posterior chain while using the anterior core to lock down the ribcage and help provide spinal stability.
The Dowel Rod Hip Hinge is an excellent way to help your patients develop this motor pattern! Prescribing this movement as homework to help ingrain proper motor recruitment with frequency allows the therapist to accelerate motor learning, opening up the door for you to load the pattern in-clinic & challenge integrity by adding variables such as strength, speed, power, and instability.
Take a look at the video below for a quick lesson on identifying improper hip hinge mechanics and how to mix them!
EPISODE 89 | Dowel Rod Hip Hinge Mechanics . As we've discussed in the past two episodes, mastering a proper hip hinge is incredibly important. . A proper hip hinge helps the trainee recruit their posterior chain musculature: Glutes 🍑, hamstrings, spinal extensors. . Developing a strong posterior chain is UNDERRATED & can often help alleviate knee & back pain!💪🏽 . 🚨Here's a quick list of what you DON'T want to do!🚨 . ❌Allow the knees to cave inward . ❌Lift the toes up and roll onto your lateral foot . ❌Extend at the neck, leading to excessive spinal extension & loss of contact with the dowel . ❌Rounding at the back, increasing strain on the vertebral bodies/discs & losing contact w/ the dowel at the sacrum. . . So what makes a proper hip hinge??? . ✅ Screw the feet into the groun, creating external rotation torque that will help the knees travel out over the ankles for optimal force production 💪🏽 . ✅ Hips drive straight back, showing a smooth posterior weight shift 👍🏽 . ✅ Minimal forward knee travel, maximizing the tension on the posterior chain! 📈 . ✅ Maintain three points of contact with the dowel at all times ➡️ This ensures neutral spinal loading throughout the motion! 1️⃣ Back of the head 2️⃣ Between the shoulder blades 3️⃣ On the sacrum, between your butt cheeks! . . Questions, comments, concerns? Drop a line in the section below! . Please like & share this post with a friend who is always complaining of knee or back pain! They likely could use some hip hinging in their life! . #StoutTraining #DPTstudent #PosteriorChainGang #PerformBetter
🚨Here’s a quick list of what you DON’T want to do!🚨
❌Allow the knees to cave inward
❌Lift the toes up and roll onto your lateral foot
❌Extend at the neck, leading to excessive spinal extension & loss of contact with the dowel
❌Rounding at the back, increasing strain on the vertebral bodies/discs & losing contact w/ the dowel at the sacrum.
What should we focus on?
✅ Screw the feet into the ground, creating external rotation torque that will help the knees travel out over the ankles for optimal force production 💪🏽
✅ Hips drive straight back, showing a smooth posterior weight shift 👍🏽
✅ Minimal forward knee travel, maximizing the tension on the posterior chain! 📈
✅ Maintain three points of contact with the dowel at all times ➡️This ensures neutral spinal loading throughout the motion!
1️⃣ Back of the head
2️⃣ Between the shoulder blades
3️⃣ On the sacrum, between your butt cheeks!