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16
Dynamic
Neuromuscular MANUAL THERAPY
Stabilization ®
1. Soft tissue techniques
§ Release pectoral and thoracic fascia
according to Kolář
§ Release intercostal spaces
§ Release postero-lateral aspects of abdominal wall
TREATMENT OF THE §
§
Release
Release
auxiliary respiratory muscles
abdominal wall
INTEGRATED SPINAL STABILIZING SYSTEM: 2. Mobilization
§ Spine
DNS THERAPY § Ribs
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ACHIEVE NEUTRAL POSITION OF THE CHEST
IAP DISTRIBUTION WITH CORRECT
ACTIVATION OF DIAPHRAGM
Flared ribs Correct position
Manual contact Thera-Band
§ Abdominal wall § Breathing against the
resistance
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IAP DISTRIBUTION WITH CORRECT IAP DISTRIBUTION WITH CORRECT
ACTIVATION OF DIAPHRAGM ACTIVATION OF DIAPHRAGM
§ Eccentric contraction and
§ Physiological movement
ideal tone of abdominals,
of diaphragm must be part paraspinals, QLs, serrati
of any movement and post. inf.
exercise
§ IAP equally increases in all
§ Centrum tendineum
directions
descends down
§ Abdominal organs are
§ Lower ribs spread out pushed caudally
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Dynamic Neuromuscular Stabilization 1
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PRINCIPLES OF DNS TREATMENT PRINCIPLES OF DNS TREATMENT
Critical component of DNS concept § Well centrated support
§ All joint centration
§ Active exercise addresses not only muscles, but also the
CNS (BRAIN EDUCATION) § Muscle coordination and balance
§ The movement must be slow to promote awareness of § Spine uprighting
the movement (BODY AWARENESS) § Correct respiration
§ Quality of the movement more important than Quantity § Resistance must be adequate to level of quality and
stabilization
§ Patient must be able to distinguish
§ The resistance must be adequate to the weakest
between correct and incorrect performance segmental link of stabilizing system
§ DNS exercises must be integrated into ADL § Micro-progression in loading
§ Adequate progression (from stabile to more unstable
position)
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EXERCISE AGAINST RESISTANCE EXERCISE AGAINST RESISTANCE
Planned = Anticipatory movement is resisted! Planned = Anticipatory movement is resisted!
Stepping forward Arm Stepping forward Leg
§ Shoulder: FL, ABD, ER § Hip: FL, ABD, ER
§ Elbow: Semi-FLEX
§ Knee: FLEX
§ Forearm: from PRO to SUP
§ Foot: PRON, more towards DF
§ Wrist: Radial deviation, MTC ABD, grasp-like position
Supporting Leg
§ Supporting Arm
§ Hip: Towards - EXT, ADD, IR+ ER activity
§ Shoulder: Towards - EXT, ADD, IR
§ Elbow: held Semi-FLEX § Knee: Towards EXT
§ Forearm: PRON § Foot: SUP more towards PF
§ Wrist: Radial deviation, MTC ABD, grasp-like position § These are movements you may resist during
active exercise
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PRINCIPLES OF DNS TREATMENT 1.TO IMPROVE THE SAGITTAL STABILIZATION
Sagittal stabilization ensures: § Manual release of rigid
segments which impede
1. Centration of segments (focusing on support neutral initial position (joint
mobilizations, soft tissues
points) technics,etc):
§ C, T, L spine
2. Differentiation of muscle function within the § Chest
global motor patterns: § Pelvis
§ Stepping forward or supporting function § Providing balanced muscle
§ In ipsi- or contra-lateral patterns activity of trunk stabilizers
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Dynamic Neuromuscular Stabilization 2
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2. TO IMPROVE THE JOINT CENTRATION 3.DIFFERENTIATION OF FUNCTIONS IN
§ Focus on global parameters GLOBAL MOTOR PATTERNS
§ Crucial is centrated positions § According to key problem find the ideal position
of the chest, spine and pelvis § in ipsi or contra lateral pattern
§ Local parameters influenced
manually by:
§ Approximation
§ Distraction
§ Correct support
§ Active approach
§ Balanced muscle coactivation
§ Active proper support
§ in closed or open kinetic chain
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DNS TREATMENT
DNS TREATMENT
Exercise is provided :
§ In static initial position We can use:
§ Movement
§ Just the movement of § Locomotion phases,
the phasic extremity (the transition phases
initiation of the mvt OR § Initiation of movement
whole ROM)
§ Whole range of transition
§ Assisted or leaded mvt
§ Mvt imagery is required § Forwards
§ Resisted movements § Backwards
(against gravity, T band,
weight, Kettle Bell)
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THERAPY AND ACTIVE EXERCISE ACTIVE EXERCISE TO ACHIEVE
1. Manual treatment SAGITTAL STABILIZATION
§ Release of the ribcage and pelvis
§ Release of the abdominal wall and e.spinae § Activation of lower
abdominal wall, especially
2. IAP distribution with correct activation of medio-caudally from ASIS
diaphragm
3. Active exercise to achieve sagittal Instruction
stabilization § Inhale as far as above the
groin, increase the IAP
adequately
§ Exhale and maintain that
relative expansion of
abdominal wall
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Dynamic Neuromuscular Stabilization 3
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ACTIVE EXERCISE TO ACHIEVE SAGITTAL
STABILIZATION
BEFORE INSTRUCTION AFTER INSTRUCTION
Goal § First with legs supported
§ Spine axially elongated
§ Chest in expiratory
position
§ Parallel position of
diaphragm and pelvic
floor § Later without legs support
§ Equal distribution of IAP
independent on
respiration
§ Equal activation of
abdominal wall
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VARIATIONS OF ACTIVE EXERCISES ARM FLEX/EXT – OPEN KINETIC CHAIN (OKC)
§ Movement of extremities against resistance
§ C-spine flexion without chin poke § Sagittal stabilization
§ During any movement of extremities/head sagittal § Isolated movement in glenohumeral joints
stabilization must be established independently
on respiration (humerus is moving in glenoid cavity)
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LEG FLEX/EXT – OPEN KINEMATIC CHAIN LEG FLEX/EXT – OPEN KINEMATIC CHAIN
(OKC) (OKC)
§ Sagittal stabilization § Sagittal stabilization
§ Isolated motion in the hip § Isolated motion in the hip
(femur is moving in acetabulum) (femur is moving in acetabulum)
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Dynamic Neuromuscular Stabilization 4
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VARIATIONS OF ACTIVE EXERCISES VARIATIONS OF ACTIVE EXERCISES
Isolated hip abduction
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VARIATIONS OF ACTIVE EXERCISE
VARIATIONS OF ACTIVE EXERCISE
§ Exercise in position corresponding to 5th or
6th month
§ BUT NEVER are posterior pelvic tilt, lumbar
spine flexion, or shoulder protraction present
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ACTIVATION OF DNF ACTIVATION OF DNF
§ Uprighting of C-spine
§ T4 stabilization
§ SCM, Scalenes
relaxed
§ Activation of DNF
towards T4
§ By pushing C spine
against the fingers Scapulae in abduction and
§ By C-spine flexion support
T4 punctum fixum for DNF
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Dynamic Neuromuscular Stabilization 5
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EXERCISES IN SITTING POSITION
EXERCISES IN SITTING POSITION –
(8-9 MONTH OF DEVELOPMENT) ACTIVATION OF ABDOMINALS
§ Lean trunk back about
20 degrees
§ Spine straight
§ Pelvis and chest in
neutral position
§ Symmetrical
distribution of IAP
§ C spine in line with the
rest of spine
§ Activation of DNF
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EXERCISES IN SITTING POSITION - EXERCISES IN SITTING
CHEST POSITION + ACTIVITY OF DNF POSITION - SHOULDER
§ Manual contact on the BLADE POSITION
sternum and T spine
“sandwich” § Sitting, spine uprighted
§ Chest is taken into caudal § Manual contact on the
position scapula and anterior
§ Approximation toward neutral part of shoulder girdle
pelvis facilitates uprighting of “sandwich“
spine
§ Reach neutral position
§ Assisted inclination backward of shoulder blade (ABD
activates DNF more (if head and caudal)
in line with spine)
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EXERCISES IN SITTING POSITION - TOOLS
PRONE
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Dynamic Neuromuscular Stabilization 6
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3MM PRONE DIAPHRAGM BREATHING 3MM PRONE
Initial position corresponds to the position of DIAPHRAGM BREATHING
assessment
§ Therapists fingers on lateral side of the abdominal wall § Therapists fingers are on lumbar spine (proc.
spinosi)
Instruction
§ Client follows this facilitation as far as the lumbar
§ Inhale down in to belly against the therapist’s fingers, spine is uprighted into neutral position
keep that pressure during exhalation
§ Fotky obou způsobů
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3MM PRONE: PELVIC GUIDING
Initial position corresponds to the position of
3MM PRONE
assessment SHOULDERS PLACING
§ Manual contact on
Initial position
§ Sacrum
corresponds to the
§ ASIS
position of assessment
§ Therapist guides pelvis into neutral position
§ Patient's goal is to maintain position when manual § Manual guiding of the
contact is removed scapulae into caudal
neutral position
§ Manual approximation of
the scapulae to the chest
and to support (medial
epicondyles of elbows)
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3MM PRONE 3MM PRONE
HEAD GUIDING (PLACING) HEAD GUIDING
(PLACING)
Initial position corresponds to the position of
assessment § Manual
approximation
§ Manual guiding of the head into neutral from top of the
position(chin tuck) head (vertex) into
T4
§ Manual contact
on top of head
for spine
elongation
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Dynamic Neuromuscular Stabilization 7
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3MM PRONE T-SPINE CORRECTION 3MM PRONE MODIFICATIONS
Initial position corresponds to the position of
assessment § Support both elbows and
§ Manual contact on the top of kyphosis guiding T symphysis
spine in uprighting (for kyphotic spine) § Sagittal stabilization
§ Then phasic movement follows
§ Head elevation
§ Head rotation
§ Lower extremity extension
§ Manual contact from below T lordosis guiding T spine
to upright
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LOW QUADRUPED LOW QUADRUPED TRANSITION
§ Beneficial for people
with excessive L
lordosis or T
kyphosis
Initial position
§ Kneeling, shins support, mild external rotation , ABD in
hips, feet out of table § Movement forward
§ Ischial tuberosities above the heels § Spine stays axially extended, elongated,
§ Elbow support on medial epicondyles movement are provided mainly in hips and
§ Pelvis neutral glenohumeral joints
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LOW QUADRUPED RESISTED MOVEMENT QUADRUPED
§ Phasic movement of stepping forward arm
with/without resistance § Approximation in to
the glenoid cavity to
§ All segments are integrated (supporting, moving) improve centration of
§ Resistance of ABD, ER, FLX, supination or the shoulder blade
specifically only one component of motion
§ Approximation in to the palm to improve
hand support
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Dynamic Neuromuscular Stabilization 8
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QUADRUPED QUADRUPED
§ Axial trunk rotation against resistance without
§ Approximation in to the hip to improve pelvic distortion
support on shins and activate IAP
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MODIFICATIONS OF QUADRUPED POSITION MODIFICATIONS OF QUADRUPED POSITION
§ Palms or knees on unstable
surface
• Exercise on the big gym-ball
§ Pelvis (or thighs on unstable
surface) • Slow movement of the legs:
flexion-extension
§ Rythmic stabilization
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SUMMARY
Cooperation of patient is needed:
§ Motivation of patient
§ Variations of position, number of repetitions, volume of
loading is strictly individual and can vary in one patient
§ Home exercise on daily basis
§ Opportunity of self correction or be checked
§ Short exercises which can be provided in ADL (working
position,…)
§ 3-5 times a day for 6-8 weeks with focus
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Dynamic Neuromuscular Stabilization 9
