Dave Juehring DC, DACRB Director Rehabilitation and Sport Injury Department and Rehabilitation Residency Palmer Chiropractic Clinics Davenport IA

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1 Dave Juehring DC, DACRB Director Rehabilitation and Sport Injury Department and Rehabilitation Residency Palmer Chiropractic Clinics Davenport IA Dynamic Neuromuscular Stability the Czech Approach to Stability Dynamic Neuromuscular Stabilization A Developmental Kinesiological Model 1

2 WHAT IS DNS? DNS is not merely a technique, but rather an overall strategy to better understand the neurophysiological principles of the locomotor (movement) system. It includes both a knowledge and theoretical base, in addition to assessment, treatment, exercise and functional strategies. What is DNS? It is an unique manual rehabilitative approach to activate the Integrated Stabilizing System (ISS) for the purpose of achieving exciting levels of improved function WHO IS THE DEVELOPER OF DNS? Prof. Pavel Kolar, PaedDr., Ph.D. Director Clinic of Rehabilitation and Sports Medicine 2nd Medical Faculty Charles University Prague, Czech Republic 2

3 Influenced by: prof. Karel Lewit Prague school of rehabilitation Prof. Václav Vojta Prague school of rehabilitation Influenced by: prof. Vladimir Janda Ludmila Mojžišova and many others Postural Ontogenesis & Developmental Kinesiology Definition of ideal functional patterns 3

4 POSTURAL ONTOGENESIS Genetically determined and comes into play automatically depending on CNS control & Afferent stimuli. Neonatus POSTURAL DEVELOPMENT 6 months Ensures active posture all possible positions in the joints determined by their anatomical shapes Postural Ontogenesis Function of the muscles is encoded in the motor patterns Motor patterns (programs) are formed as CNS matures, enabling infant to control posture, achieve erect posture against gravity and to move purposefully by phasic muscular activity. Motor development of the child demonstrates ideal motor patterns DEVELOPMENTAL KINESIOLOGY Emphasizes the existence of Central Locomotor CNS Control The infant does not need to be taught when and how to lift the head, grasp the toy, turn around or start crawling All this should occur automatically in the course of the CNS maturation These functions are triggered in the genetically pre determined sequence Specific motor patterns characteristic for certain developmental age allow for clinical assessment We can define the developmental age of the child by assessing achieved quality and stage of the motor patterns 4

5 Epiphyseal line = growth plate CNS Program Brain and CNS pathways mature after birth Level and quality of the CNS maturation correspond with the level and quality of motor patterns Muscle Function Coordinated co contraction of antagonists Harmonious influence on growth plates possible only if the CNS functions normally Critical for ideal structural development Joints Every joint position depends on stabilizing muscle function and coordination of local and distant muscles to ensure centration The quality of muscle coordination is crucial for joint function CNS dependent DEVELOPMENTAL KINESIOLOGY Helps us understand how certain muscle synergies come into play: how individual (even far distant) muscles are inter related (functional coordination) We can define the developmental age of the child assessing achieved quality and stage of the motor patterns 12 months 3 months 9 months Postural activity occurs as a result of CNS maturation 5 months 7 months Level/quality of CNS maturation corresponds with the level/quality of posturallocomotion function & stabilization 8 months 9 months 5

6 What is necessary for physiological motor development: Normal intrauterine development Physiological Healthy Brain (CNS) EMOTIONAL MOTIVATION Sensory information: sight, hearing, vestibular function, proprioception AFFERENT INPUTS THEN Postural activity occurs automatically in the course of maturation of the CNS by muscular coordination Stabilization & Locomotor patterns are of ideal quality Neonatal Period: First 4 weeks of the life Postural Activity = Spontaneous Motor Behavior Generalized global kinetic movements that are not caused by a specific stimuli Holokinetic movements Not purposeful writhing like movements of the neonate ( 0 3 weeks) No equilibrium No co contraction between agonist and antagonist possible Baby cannot hold a segment out of the support base If one segment moves, whole body moves Newborn Posture Hand finger flexion, UD, wrist flexion, thumb inside fist Forearm flexion & pronation Shoulder IR & protraction Scapula Elevation Predominance of the tonic muscular system is characteristic Spine kyphosis Pelvis anterior tilt Chest inspiratory position Hip flexion, IR Knee flexion, ER Foot PF 6

7 Newborn Stage (cont.) Incapable of purposeful movements Abdominal breathing pattern No segmental movements All movements are generalized involving the entire locomotor system 6 weeks 4.5 months: Core stabilization develops Spine, chest and pelvis is stabilized in sagittal plane Basic sagittal stabilization is prerequisite of any phasic movement by extremities (stepping forward, supporting, reaching, grasping function) & also lifting the head Body segments are stabilized against any external force (load) 7

8 3 months Support: Elbow Elbow Symphysis Medial epicondyle of the elbow Elbow at the level of the shoulders Co activation simultaneous activation between agonist and antagonist Necessary to stabilize torso in gravity field Prone: C spine extension starts from T4/5 Intra abdominal pressure regulation allows baby to lift legs Isolated head rotation without trunk synkinesis possible Coactivation stabilizing spine, chest and pelvis is completed at 4.5 months What is necessary.?? TO LIFT HEAD? Co activation = balanced, proportional, simultaneous activity between (DEEP) neck flexors and extensors TO LIFT LEGS AND PEVLIS? Co activation = balanced, proportional, simultaneous activity between diaphragm, pelvic floor, all the sections of abdominal wall = IAP regulation In balance with spinal extensors Sagittal stabilization allows for Functional joint centration Dynamic neuromuscular strategy that leads to the optimal joint position that allows for the most effective mechanical advantage The centrated joint has the greatest interosseous contact to allow for optimal load transference across the joint and along the kinetic chain. Allows for maximum muscle pull / Implies maximum load bearing Protective (passive structures) 8

9 Development of Functional Joint Centration Position of joints is controlled by coordinated cocontraction of antagonists. Also linked up with muscles providing joint stabilization. Well balanced activity of antagonists ensures wellcentrated joints and this depends only on a normally developed CNS. Stabilization in a sagittal plane: 4.5 months Functional centration of all the joints Maximum contact of articular surfaces Ideal for loading the best biomechanical advantage at each joint position Baby & weightlifter same pattern of stabilization, same coordination. Weightlifter only needs more strength, however, biomechanical conditions and coordination is the same! 2 nd phase of development limb differentiation between 5-12 months: Stepping forward and supporting function of the extremities Ipsilateral pattern Contralateral pattern 9

10 Ipsilateral pattern Contralateral pattern 3 7 months Ipsilateral pattern develops from supine position Contralateral from prone position After 7th months Baby starts to switch between ipsi and contralateral pattern Combines both patterns in spontaneous movements Stepping forward (reaching, grasping) extremities Opened kinetic chain Fixing point: proximal Moving point: distal Distal segment moves against the proximal Proximal direction of muscle pull Supporting extremities Closed kinetic chain Fixing point: distal Moving point: proximal Proximal segment moves against the distal Distal direction of muscle pull 10

11 5 months: starts turning 1st oblique abdominal muscle chain: pulls the pelvis in the direction of rotation towards the supporting arm 6 months: turning completed 2nd oblique abdominal muscle chain: Pulls (rotates) the upper part of the body towards the contralateral ASIS Straightening up on the supporting elbow Ipsilateral pattern 11

12 Ipsilateral pattern/shoulder & pelvic axis ALWAYS PARALEL 5 th MONTHS WB on medial elbow, < 90 shld flexion WB on pubic symphysis and L-S area - time where the pelvis reaches neutral position and there is a coordination between pelvic floor and diaphragm muscles to produce the intra-abdominal pressure for stability Contralateral pattern 12

13 Contralateral pattern/shoulder & pelvic axis ALWAYS CONVERGE 8 th 16 th month: quadrupedal bipedal locomotion: Verticalization All patterns based on the same principles: Stabilization & stepping forward and supporting extremities function Ipsi or contralateral pattern DK AND MOTOR PATTERNS Motor patterns maturing after birth are basic movement patterns used during adulthood 13

14 POSTURAL ONTOGENESIS (CONT.) Morphological development of the skeleton depends on the postural function of the muscles Muscular synergies always depend on body posture as a whole and not that of a particular segment Decentration of a single joint has its effect on the centration of all the other joints IMPORTANCE OF DK IN PRACTICE? Defines ideal posture from a developmental perspective Defines muscle coordination that is ideal for joint loading i.e. defines ideal motor stereotypes Describes the relationship between development during the first year of life and pathology of the locomotor system in adulthood. Do you see any difference in posture & muscle function? Ideal pattern of stabilization Poor pattern of stabilization Just compare!! 14

15 Understanding kinesiology of the postural development is essential in diagnosis and treatment of the locomotor system disturbances Developmental Kinesiology Based Exercise 4 m 4.5 m 8 m Developmental Kinesiology Based Exercise 9 m 10 m 14 m 15

16 Conclusions 2 basic functions play a decisive role Development of stabilization in the sagittal plane at the end of 4 th month Muscular stabilizing function matures, enabling the spinal column to adopt ideal weight bearing posture Development of specific phasic movements: swinging function (stepping forward or grasping) and the support function. Conclusions Disturbed activation of muscle activity during postural development may result in poor posture. Disturbed postural development is an important etiological factor of various problems in the locomotor system Never a local insufficiency but always occur in chains global patterns are disturbed Under normal conditions, both the stepping forward and support function take place according to a biomechanically ideal pattern when all the joints are functionally centrated. THANK YOU Dave Juehring Juehring_d@palmer.edu 16