Archives for November 2011

Dynamic Neuromuscular Stabilization DNS-B reviewed

I had the pleasure of visiting Athlete’s Performance Institute in Phoenix, AZ and attending Dynamic Neuromuscular Stabilization recently.

I won’t even try to fully capture the full scope of DNS in this blog.  The system, developed by Dr. Pavel Kolar, is based in developmental neurology and applies the principles of turning and creeping into assessment of the core (integrated spine stabilization system) and phasic movement of the extremities.  Understanding the anticipated movements of these inborn patterns allows us to perform resisted exercise or reflex locomotion to refresh these subcortical patterns to the standard operating procedures of cortical movement.  For those versed in the traditional chiropractic model of treating the nervous system and the innate, you have not seen more evaluation and influence of the nervous system or innate abilities than you will find in DNS.  This technique may very well be the bridge from the beginnings of our understanding to some of the contemporary developments and methods.

For those who wish to know more about DNS, follow this link.

A few key points:

  • Joint centration is essential and non-negotiable.
    -positions can be modified as needed, but joint centration must remain.
    – decentration of one joint will undoubtedly lead to decentration of another joint.  (An undesirable chain reaction.)
  •  What is centration?  Centration is the position of maximal joint contact.  This allows the most even distribution of forces through the joint as well as balanced muscular coactivation around the joint. 
  • Why do we want centration? Maximal motor control and power with minimal load/stress.
  • Breathing and abdominal bracing (spine stabilization) are intimately related and are interdependent.  Both must be maintained or the integrated spine stabilization system is compromised and stability is lost.
  • Evaluate and train in multiple positions/patterns.  The ‘key link’ Janda described will be evident in multiple evaluations.  Retraining this key link will require repetition and myelinization through training in multiple positions.
  • Newborns begin with primitive, reflexive patterns.  With afferent input (stimulation) there are genetically preprogrammed movement patterns that develop at specific neurologic ages. Failure of proper neurologic development indicates a ‘central coordination disorder’ that may be indicative of CNS pathology.
  •  “Form follows function”: failure to follow typical developmental movement patterns can have morphologic consequences.  (ex. flat foot, acetabular angle, pelvic tilt, kyphosis, etc)  Louis Sullivan coined this phrase in the world of architecture, but it clearly has its place and value in human development as well.
  • Zones of support during developmental positions create areas of dense proprioception.  These areas can be used for stimulation during isometric exercise and reflex locomotion.
  • Tactile and/or verbal cuing is used when altered motor patterns are seen.  When verbal or tactile cuing is not sufficient to improve faulty patterns, then reflex stimulation may be necessary.
  • During reflex locomotion there is a vector to follow, often towards the point of support (punctum fixum) or the next joint in a phasic limb.  The vector is not a specific direction, but within a general region from the stimulation point.  The exact vector is within a ‘cone shape’ and is determined by the clinician based on anticipatory reaction generated from stimulation.

There is a broad application of the principles of DNS as they are based on universal principles of inborn, preprogrammed movement patterns.  Applications range from evaluating and treating developmentally challenged babies, to restoration of normal movement patterns in painful or restricted adults, to allowing maximal motor control and muscle activation in elite athletes.  I should also mention that maximum distribution of joint forces is also applicable to all ages and situations as it will ensure proper development and maturation, help prevent future injury and joint pathology, and prolong athletic careers. This diverse applicability makes this system a valuable tool.

For their help in learning part B of the principles of DNS, many thanks to the folks at API (Darcy Norman, particularly as he helped out the B group), Ken Crenshaw & the AZ Diamondbacks organization, the Prague School instructors and Pavel Kolar, Clare Frank who instructed the B group, and course organizer Craig Liebenson.

The question that remains for me is, where is the line between good enough and not good enough?  With DNS functional testing there is almost always something wrong with the pattern.  From little flaws in stabilizer activation to completely inadequate coordination of breathing and bracing. What do we attack and what do we leave alone?  In FMS we talk about fixing 0s and turning 1s and asymmetries into 2s and symmetrical patterns. This is easy to follow. Valdimir Janda talked about fixing the ‘key’ link, but not getting bogged down in trying to teach perfect movement.  I’ve yet to find where this line is for DNS.  The line may be clear in the case of the elite athlete, we want everything to be as perfect as possible to give them the competitive edge.  However, for the average patient or average athlete, when do we call it ‘good enough’ vs. continuing the quest for perfect patterns.  For now I’ll try to let the clinical audit process sort it out (I’m curious to hear others opinions on this question, and if I ever come up with a more concrete answer I will be sure to post it.)

MORE INFO:
For the best review of this course I know of (including this one) see Jeff Cubos’s blog.

Interviews by Phil Snell of myrehabexercise.com during the DNS course in Arizona as follows:
Dr. Alena Kobesova -DNS interview

Dr. Clare Frank – DNS instructor interview

More interview and info available on Phil Snell’s blog.

For those looking to attend DNS courses check here.
There is a Scarsdale, NY DNS-A course in August 2012.

Stecco’s Fascial Manipulation Reviewed

I had the opportunity to take Fascial Manipulation Part 2 recently in Dallas, Texas. I thank Drs. Antonio Stecco and Warren Hammer for sharing their time and expertise in this method, as well as Part 1 in Newark, NJ in April.  Fascial Manipulation© (FM) is a technique developed by Luigi Stecco, PT over 30 years and now carried forward by his children, Carla and Antonio Stecco, who are both MDs by training.  While Luigi developed this fabulous system of analysis and treatment, his children have taken on the task of further evaluating the anatomy and principles behind Fascial Manipulation©.  Their efforts are clear with a quick search of pubmed which produced almost 100 articles during my recent search.  New techniques are often copyrighted and taught, but rarely do we see this level of effort go into supporting and explaining the methods.  Carla will also again be presenting at the 2012 Fascial Congress.

What is Fascial Manipulation©???
Let’s start with what we know from other sources…. the body moves in complex patterns and the brain activates movements, not individual muscles.  We are seeing this concept more readily adopted in the areas of functional assessment and functional training, but have not seen it to any great extent in the soft tissue world.  Many techniques are still teaching treatment of individual muscles.  (One notable exception is FAKTR.)  With the concept of movement patterns in mind Stecco’s Fascial Manipulation teaches movement verification (MoVe) through assessing movements based in each plane of the body (sagittal, frontal, transverse).  Dysfunction in these planes is detected and then narrowed to a particular region by limiting the number of regions involved in the MoVe.  (This assessment method reminds me of the SFMA breakouts.)  Planes are dedicated an abbrevaited as follows: (Sagittal Plane: an-Ante, re-Retro; Frontal/Coronal Plane: le-Latero, me-Medio;  Transverse/Horizontal Plane: ex-Extra, and in-Intra).  The ‘sequences’ of points drawn through these planes/lines are similar to the lines drawn in Anatomy Trains by Tom Myers, however the detail and clinical application in Fascial Manipulation: Practical Part is much more detailed and clinically oriented.

Fascial Manipulation also simplifies anatomy for us and creates a common language for practitioners around the globe to speak.  For example: Any point in the head is known as Caput, abbreviated, cp.  Any point in the neck is Collum, cl.  (Arm=Humerus=hu; Forearm=Cubitus=cu; Lumbar=Lumbi=lu; Pelvic=Pelvi=pv; Coccyx=cx; etc).  There is no differentiation of individual muscles, ligaments, or tendons although reference to these familiar anatomical structures are used to help practitioners learn the Centers of Coordination (cc) which are points of possible densified tissue to be evaluated by palpation and possibly treated and Centers of Perception (cp) which are the areas where symptoms are reported.  For example finding the cc or cp referred to as Anterio-Collum (an-cl).  [While a bit confusing at first the language becomes second nature quickly…. finding the points on the other hand takes a bit longer.]  Finding these points through palpation is the second step in FM.  Step 1: MoVe. Step 2: Palpatory Verification (PaVe).  The most densified, most painful, or points with the most radiation are compared to MoVe and treated.

In Part 2 of Fascial ManipulationFascial Manipulation Dallas Class  Centers of Fusion (CF) are introduced.    From the Fascial Manipulation Workshops website: “While CC points regulate unidirectional muscle fibers of a single mf unit, CF coordinates intermediate muscle fibers, activated during movements between mf units. Luigi Stecco realized that it was necessary to coordinate two or three myofascial units involved in complex global movements where the forces of myofascial units converged. CF will be taught to be used for single segments, along myofascial diagonal and myofascial spirals.”

After MoVe and PaVe assessment, the results of the 2 are compared.  Points are selected along the most significant plane.  Typically several points (perhaps 3-5) are treated in each session.  While the majority of these points will come from the most significant plane, a point or two from the antagonist sequence is also treated, and any relevant CF points can be treated as well.  The ultimate goal is balance of the fascial system which is designed to reduce altered stress and strain on joints, reduce symptoms, and improve fascial proprioception contributing to faulty movements.

Intro to Stecco’s Fascial manipulation (youtube video 1min 39sec)
Antonio Stecco – Shoulder Tx (FM Assessment & Treatment with Antonio & Carla 12min 31sec)
Interview with Drs. Warren Hammer & Antonio Stecco
(6min 49sec)

An incomplete technique:

Despite the many significant connections, the incorporation of movement patterns analysis in evaluation, and the authenticity of a system that requires test and retest improvement within the same visit (like McKenzie or the Clinical Audit Process), Fascial Manipulation© is an incomplete system.  I say this not to detract from the exceptional work of the Stecco family, or to lessen the value Dr. Warren Hammer added by bringing this work to the U.S., but to acknowledge that for many with soft tissue dysfunction FM can serve as a starting point, but not an end point.

Concepts significantly lacking from FM include movement pattern training and failure tolerance.  There is an interplay or overlap of these 2 concepts, as you will see below.  Research has shown presence of proprioceptors within fascia and it is hypothesized that this plays a significant feedback role in controlling and coordinating movements and I believe it does.  However, we fail to acknowledge that movement patterns come in 2 forms; inborn pure patterns and those developed from habit and repetition.  Despite removal of densifications in fascia and associated improvement proprioceptive feedback the system does not retrain faulty movement patterns, which are programmed in the CNS, nor does it reactivate the natural inborn movement patterns (see DNS for how this can be done).  Allowing someone to continue operating with faulty mechanics will lead to accumulation of stress/strain, eventual crossing of a tissue’s failure tolerance, and then reinjury.  Without addressing this component FM is in my opinion an incomplete system.  Further, we know that failure tolerance can be increased through appropriately loading of tissue (see Stuart McGill’s work or research on eccentric loading of tendons).  Proper levels of strain can increase tissue strength and resilience which alters failure tolerance.  Failure to address this component in a previously injured tissue also detracts from the outcomes of FM treatment.  A final note on tissue tolerance; incorporation of microbreaks during prolonged or repetitive activities have been shown to have significant impact on how quickly a tissue reaches its failure point.  Instruction and education in this principle would also be a nice addition during a course of FM treatment.

For those looking for ways to teach/train appropriate functional movement patterns, to appropriately engage stabilizing musculature, and for patient review of microbreaks you may wish to check out, www.myrehabexercise.comIn addition to instruction, this site can help reduce the time and effort needed to reinforce your Fascial Manipulation in Dallas with Antonio & Warrenin-session training with proper home instruction for your patients.  (I had the opportunity to spend some time with the sites creator, Dr. Phillip Snell, during breaks at the Fascial Manipulation 2 seminar, and believe he and I see eye to eye on the addition of these principles to the FM technique.)

To reinforce the concepts above, I present the following analogy. Imagine playing soccer on a field atop a hill.  Now let’s imagine that the field shrinks to the size of a basketball court, or indoor soccer pitch if you prefer, or perhaps even smaller.  Imagine the challenge of keeping the ball on top of the field and keeping the game going.  In FM we are thinking of balancing forward movement (an) with backward movement (re) as well as lateral movement (la) with medial movement (me).  The same is true in the oblique directions (ir, ex).  If we balance our movements with each plane, like kicking the soccer ball around our small field, it will remain atop the hill and we can continue to play and enjoy our game.  When the balance is disrupted, for example too many kicks to one side, the game stops as the ball rolls down the hill.  The stoppage of our game would be similar to crossing a tissues failure tolerance or suffering an injury.  With FM treatment we can restore balance and get the ball back into the middle of the field, but what prevents this from occurring again?  (Remember we’re playing on a small field.)  Teaching movement pattern training would be analogous to teaching the players of this soccer game better ball control (they are less likely to have uncontrolled forces or unexpected vectors on their kicks) and the ball will likely stay atop the hill.  Therapeutic exercise (such as stability training or eccentric loading) can increase the failure tolerance of tissues, this would be analogous to taking our small field and expanding it back to the dimensions of a standard field (allowing more margin for error and greater forces within the game).  By doing either of these we increase the likelihood that the game continues. To review my obscure analogy, the goal of FM is to balance tissue tension, like trying to keep our ball in the center of the field.  This technique is well-developed, with emerging research, and clinically applicable concepts.  However, trying to keep our ball in the center of the field, without giving significant consideration to training ball control, and ignoring the fact that the field size could be increased, creates a situation where recurrence/reinjury is more likely.

 For more information on learning Fascial Manipulation© visitwww.fascialmanipulationworkshops.com

FMS Study???

For those that wish to review the study, look here.

I first had this conversation with a colleague and then saw this post on Jeff Cubos’s Blog.
This study is well performed, but poorly designed.  The premise, as Jeff points out, has significant flaws.  They are taking a “screening test” for injury risk assessment and claiming to use it to measure athletic performance.  To compare how odd this is let’s think about drawing blood and measuring lipid profiles to determine the fastest runner.

A comment left on Jeff’s blog notes that improvement in the FMS screen may be implied to lead to improved athletic performance.  While not the intended goal of the screen (it is designed to test for risk of future injury), I can see that this would make sense.  For example, an athlete who scores a 13 (out of 21) and then participates in a corrective exercise program and a few weeks later able to score a 16 (with no asymmetries); I would assume that some translation to on the field performance may exist.  (Although again, this is not the goal of the FMS test.)

Parchmann & McBride not only begin their study with a flawed concept but seem to bias the test results as well.  In comparing a movement literacy test (FMS) to a power-based movement (1RM back squat) the researchers chose to use the following as benchmarks: sprint times (10m, 20m), vertical jump, T-test, and golf club head speed.

Exceptional workout power; limited performance

Suffice it to say that these are all power based movements.  The most powerful athlete will likely get the highest marks on each of these tests and therefore it is expected that a 1RM test correlates better than the FMS test.  However, this does not correlate well into determination of the best athlete.  [Think Brian Bosworth vs. Brian Urlacher].

Great workout; exceptional performance

To put this another way, I can swing a golf club really fast… however the score at the end of my round is nothing I care to brag about.  Swing velocity is not a good indicator of the best athlete, it’s indicative of the most powerful.

To recap:

  • I applaud Parchmann & McBride‘s effort to test the FMS screen.  We should challenge all concepts and make sure that we’re using what works best and not holding onto sacred cows or simply doing what “should work”.
  • This study has significant logical flaws as the FMS test is misinterpreted from the beginning and the authors base their conclusions on the flawed premise that the most powerful athlete is the best athlete.
  • As I suspect there is a mild degree of correlation from the FMS score to ‘coordinated movements’, I would be curious to see this compared to putting or chipping accuracy, or perhaps driving closest to a center line.  These non-power skills likely have little correlation to 1RM and may have some correlation to FMS scores. However we must remember that this was never the stated (or intended) purpose of the FMS test.

How do you lift your weights???

While attending a seminar hosted at Peak Performance in NYC, I was impressed by the high level of training offered by Joe Dowdell and his staff.  [visit Peak Performance on facebook] Even as Joe and his staff joined us in the Functional Assessment seminar, workouts continued in the gym with excellent instruction.  The hallmark of quality training is making an exercise ‘challenging’ while maintaining good form, simply making an exercise ‘hard’ (adding weight, doing it faster, performing more reps or sets) is easy to do, but doesn’t produce quality results.  The ‘hard’ way is the hallmark of lesser trainers.  I was impressed by high caliber and ‘challenging’ exercises I saw while at Peak, and I think the contrast with what I saw next is what made it so apparent.

After watching an exceptional set of plank rolls, the athlete stood up, his trainer went to prepare the next exercise, and I watched the athlete bend into complete lumbar flexion with no hip hinge to pick up his water bottle.  Great form and core control in exercise should translate to the same in everyday activities, it clearly did not here.

I saw a similar episode after watching some well done box jumps.  The exercise was performed with quickness, balance, control of a neutral spine, and stability at the hip evident by no medial collapse at the knee or trendelenburg’s sign at the hip.  Upon completing the set, the trainer began to put the box away and the athlete bent over to retie her shoes.  Something like this:

Note extreme lumbar flexion, failure to hinge at the hip. This is not a spine sparing or load sharing strategy.

I was surprised both times this happened. It was clear to me that the athlete understood proper form from the way they performed the exercise. It was clear the trainer understood quality ‘challenging’ exercise from the standard they set for the athlete.  However, there was no translation into activities of daily living.

After thinking about this, I realized that this happens in my office as well.  I spend time training patients in the hip-hinge, proper lunge mechanics, and other spine-sparing strategies so they can continue functioning without aggravating their condition.  In addition to teaching this I explain disc loading (see chart below) and try to follow the teachings of manual medicine pioneer Karl Lewit, MD, “The first treatment is to teach the patient to avoid what harms them.”  However, on occasion that same patient at the end of their visit reaches down to put on their shoes, pick up there purse, or collect their wallet and cell phone and performs the exact movement we just trained with improper form.  I take the opportunity to remind them, they often have a surprised expression, and together we work to repeat the activity with a more spine sparing strategy.

Are you loading your back unnecessarily?

The challenge for the clinicians and the trainers out there… first recognizing improper movement strategies and training good form; second getting good form incorporated into activities of daily living, work duties, and recreational activities through functional training and repetition.  We need our patients and athletes to understand this connection and then we need to work on repetition to myelinate these quality pathways. That which we wish to do with ease, we must first do with frequency.

  1. Teach correct movement patterns. (choose spine sparing, painless, dysfunctional patterns to correct)
  2. Repeat and groove these patterns.
  3. Make movement patterns more complex and add functional challenges.
  4. Add stability.
  5. Build endurance.
  6. Add speed, power, or stability training.

The common thread here is that it is not what we can do it’s what we actually do that determines injury risk.  Much like Professor Stuart McGill’s critique of FMS or similar screens. A simple but brilliant comment. A great analogy is diet and nutrition.  If someone can demonstrate that they can make a healthy, balance, nutritious meal, but they instead choose to eat fried fast food, what is their health risk?

To be truly effective, an athlete or patient’s ability to perform quality movement in the office and/or gym must translate into proper movements during daily activity.

Imaging Adolescents

“No Imaging Needed For Most Low Back Pain”
http://www.medscape.com/viewarticle/752771

From the American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition and research of Denis Drummond, MD the following facts on back pain and imaging of adolescents:

  • mechanical low back pain is common in the pediatric population
  • recent studies have shown that undiagnosable mechanical low back pain accounts for up to 78% of cases in adolescents (we can’t always identify the exact cause, this is true in adults in 85% of cases per Deyo & Weinstein in 2001 in the New England Journal of Medicine) 
  • a child absorbs more radiation and their metabolism is much greater than an adult’s (radiation is likely more harmful to young)
  • attempt conservative management first. After 6 weeks a 50+% improvement should be seen, if so continue with conservative care.  If not, imaging and further investigation is warranted.

Most of these recommendations are not dissimilar from adult clinical guidelines and best practices.  While back pain in children is concerning, we must remember it is not uncommon and is often treated successfully with conservative care allowing us to avoid radiation.  The other aspect is the limited value of imaging as noted in “Is Your Telephone Ringing“.  This is not to say that at times imaging isn’t necessary and appropriate.  Imaging should be used in cases of significant trauma or abnormal presentations to evaluate for conditions such as: fracture, dislocation, infection, tumor, cauda equina syndrome, or with stress views to assess joint instability.

Appropriate and judicious use of imaging controls costs and avoids risks of unnecessary testing, treatment, and radiation.

Sue Falsone – Breaking Barriers

The Dodgers are known for breaking barriers.  The most notable example is of course Branch Rickey’s hiring of Jackie Robinson, the first African-American major league baseball player.  The newest is Ned Colletti’s hiring of Sue Falsone, PT, MS, SCS, ATC, CSCS.   Sue will be the first female head athletic trainer in any of the 4 major U.S. pro sports.  A well deserved honor. In addition to her work at Athlete’s Performance Institute, Sue lectures on bridging the gap between rehab and performance training, a divide that must be narrowed for successful return to competition. Navigation of this bridge is currently being improved with better communication from personal trainers, athletic trainers, and coaches who are familiar with the FMS system and clinicians (PTs/DCs/MDs/DOs) familiar with FMS and/or SFMA systems.  The gap is being narrowed (or erased) with DVDs like Charlie Weingroff’s “Training=Rehab-Rehab=Training” and interdisciplinary seminars like Craig Liebenson’s Rehabilitation of the Athlete.

I reflect on this as I prepare to head to Athlete’s Performance Institute in Tempe, AZ where Sue serves as “Director of Performance Physical Therapy, Athletes’ Performance and Core Performance, & Director of Team Sports” for an upcoming seminar in DNS.  I’m looking forward to visiting this top notch facility again.