The Peter Attia Drive - #152 - Michael Rintala, D.C.： Principles of Dynamic Neuromuscular Stabilization (DNS)

00:00:00.000 Hey, everyone. Welcome to the drive podcast. I'm your host, Peter Atiyah. This podcast,

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00:00:41.720 head over to peteratiyahmd.com forward slash subscribe. Now, without further delay,

00:00:47.740 here's today's episode. I guess this week is Michael Runtala. Michael's a chiropractor based

00:00:54.180 out of San Diego, California, where he has a practice that focuses on rehabilitation,

00:00:59.080 which is how I met him. In addition to his practice treating patients and training a wide

00:01:04.680 variety of patients, he's also one of only 18 international instructors for the Prague School

00:01:10.480 of Rehabilitation, teaching dynamic neuromuscular stabilization, also known as DNS. He serves as

00:01:17.640 part of the PGA Tour sports medicine team and the USA surfing performance committee. This is an

00:01:24.020 episode that's really dedicated to understanding the Prague School of Rehabilitation and DNS or

00:01:30.100 dynamic neuromuscular stabilization, which many of you have probably heard me talk about in the past.

00:01:36.120 It came up a little bit during the podcast with Beth Lewis, and it's come up on a few other

00:01:41.460 podcasts. It also comes up from time to time in social media. When I post videos of some of the

00:01:47.000 movements that we do in our DNS training, in this episode, we get into the history of DNS,

00:01:53.020 which is a relatively new discipline. It's really been around less than 20 years and how it grew out

00:01:57.960 of the Prague School of Rehabilitation, who the effectively the founding fathers of that school

00:02:03.040 of thinking were dating back to the 1950s. We then kind of get into how the developmental milestones

00:02:10.160 of an infant factor into or weigh into basically things that anyone listening to this should care

00:02:16.800 about, which is how they move and how they function and how they avoid injury and maintain longevity.

00:02:21.540 So this is a complicated episode in the sense that I have to be honest, I think some of the concepts

00:02:26.400 here don't always lend themselves well to discussion. I think being able to watch this on video gets a

00:02:32.560 little bit easier because at least, you know, you can see some of the hand gestures. And of course,

00:02:36.140 this episode will be accompanied by a video where Michael, Beth, and I go through many of the

00:02:44.940 foundational movements. Now that video will be available only for the subscribers, but I certainly

00:02:49.480 would encourage all subscribers or even non-subscribers to sign up to make sure that they

00:02:53.500 see that. Cause I think that's where a lot of the heavy lifting gets done. Ultimately, of course,

00:02:57.320 DNS is something that needs to be felt more than watched. So my real hope is that most people try to

00:03:04.380 put some of this into practice and begin to experience it. So without further delay,

00:03:08.580 please enjoy my conversation with Michael Rintala. Hey, Michael, thanks for coming all the way out

00:03:19.440 to Austin to work on some DNS for a few days with me and Beth. Thanks for having me. Thank you.

00:03:25.060 Been wanting to sit down for quite a while and obviously the events of 2020 kind of got in the

00:03:29.820 way of that, but maybe just start for folks by giving a little bit of your background. You grew up

00:03:35.080 in Northern California, right? Yeah. Grew up in Northern California and eventually went to school

00:03:41.800 down in San Diego at UC San Diego. What sports did you play growing up? My primary sport or the sport

00:03:48.980 that I was most passionate about was tennis and interested in that from an early age. Played other

00:03:58.260 sports, other organized sports, but tennis was the one that I was drawn to and had the passion for.

00:04:05.080 So early on, specialized in that, played lots of junior tennis tournaments, trained a lot,

00:04:12.720 eventually played in college. And that obsession or passion kind of drove me to the way that I

00:04:23.800 practice today. I'm a chiropractor. I'm based out of San Diego, California, as you know.

00:04:29.080 I specialize in rehabilitation, sports medicine. I am also, so I have the private practice there.

00:04:36.860 I'm fortunate enough to also be able to spend some time on the PGA tour and the World Surf League tour

00:04:44.020 as part of their sports medicine crew or team. And also fortunate enough to be part of USA Surfing

00:04:54.080 Performance Committee, helping with assessing and training the US athletes, the surfing athletes

00:05:00.960 for the upcoming Olympics. Cool. Today, obviously, the thing we want to talk about is this super

00:05:07.360 kind of deep dive into something called dynamic neuromuscular stabilization. Now, folks listening

00:05:12.720 to this have probably heard me talk about this in the past. They follow me on social media. They'll

00:05:18.440 notice from time to time. I'm doing movements that probably look a little silly, sometimes working

00:05:25.080 with you or working with Beth or working with another colleague of ours, Michael Stromsness is

00:05:29.180 actually how we all met. But I think for the purpose of this discussion, let's assume a person has never

00:05:35.740 heard of DNS, has never heard of the Prague School or any of these things. Can you, in a somewhat

00:05:44.500 succinct, but not terribly brief manner, explain to people how all of this school of rehabilitation

00:05:52.660 coalesced around this idea of what we call DNS? So going back to the founding fathers of the Prague

00:06:00.020 School and what these various insights were that each of them had and how that sort of came together.

00:06:05.620 So DNS, or dynamic neuromuscular stabilization, kind of built on some pioneers of functional

00:06:14.180 rehabilitation. There's many that have been part of the Prague School of Rehabilitation, but I think

00:06:20.820 talking about the influence on the development of dynamic neuromuscular stabilization by Professor

00:06:29.460 Pavel Kolaj, who runs the rehabilitation department at Prague School at this time, I think we need to go

00:06:37.860 back post-World War II, Cold War era, 1950s, is where Prague School of Rehabilitation was really founded. And it was

00:06:50.660 founded as part of the medical faculty of Charles University in Prague in the Czech Republic, or formerly

00:06:58.740 Czechoslovakia and now Czech Republic. And being post-World War II, Cold War era, so they were in Eastern

00:07:07.380 Europe behind the wall, that may have been a factor for their, not reliance, but tendency towards the use

00:07:15.540 of observation in both diagnosis, both observation and palpation for diagnosis and treatment. All three of

00:07:26.500 these pioneers were neurologists. And who were the three? Vladimir Yanda, Carl Leavitt, and Balclav Vojta.

00:07:34.980 Professor Yanda, he had a keen sense of observation and he formulated concepts and principles that tied into

00:07:46.900 postural habituation, specifically the tendency for specific musculature to tend towards tightness and

00:07:53.460 other musculature to tend towards weakness. And he termed this upper cross and lower cross syndrome.

00:08:01.860 So for example, with an upper cross syndrome, meaning the neck and shoulder region,

00:08:08.260 with demands of life and the tendency towards postural habituation, such as with sustained seated

00:08:16.100 postures, there's a tendency towards the muscles in the back of the neck, the occipital muscles,

00:08:23.540 the sternocleidomastoid muscle, which is the muscle that also attaches to the skull and down to the

00:08:31.140 sternocleidomastoid joint, the pec muscles, the upper traps, that musculature would tend towards a

00:08:39.540 weakness. And with that tendency towards over-utilization or hypertonicity and under-utilization,

00:09:06.740 inhibition weakness, that would also, he also recognized that that would affect the quality

00:09:14.420 of movement throughout the kinematic chain and subsequently would lead to overload in specific

00:09:22.500 areas throughout that kinematic chain. So that was a big contribution on his part.

00:09:29.620 Where would those places of overload be? So if you have this tightness in the muscles you've

00:09:35.380 described, the weakness in the muscles you've described, what is the consequence of that? Where

00:09:40.180 does that load get distributed? Right. So you, with that imbalance and that tendency towards postural

00:09:47.300 habituation, you would see a tendency to overload in the transitional areas throughout the spine

00:09:53.620 and throughout the extremity. So it didn't go into the specifics for lower cross syndrome. Lower

00:09:59.700 cross syndrome syndrome. You have a tendency for the flexor, hip flexor complex to be overactive,

00:10:07.140 tightened. So the psoas, iliopsoas, rectus femoris, the back extensor musculature will also tend towards

00:10:14.980 tightness. And then the weakness or the inhibition will tend to be towards the lower abdominal region and

00:10:22.100 the gluteal region. So looking at it globally, you would see a tendency to overload again throughout the

00:10:30.820 extremities. So that the hip joint, the knee joint, but also specifically dealing with the spine, the lumbar

00:10:37.540 sacral region, thoracic lumbar region, and the cervical thoracic region, all the areas where you see the

00:10:44.100 transition of the curvatures, lordosis and kyphosis. And with that tendency for overload,

00:10:54.500 you will get repetitive stresses on the passive structures within that kinematic chain.

00:11:01.300 So as a clinician, we know that if you tend to image these areas, or if you image the spine,

00:11:10.100 these are the areas that tend to have the most degenerative changes, or the most disc pathology.

00:11:17.380 And those changes aren't usually traumatic, they're not acute, they're accumulated over time. So

00:11:25.940 the observation of these postural patterns or postural syndromes, and then the recognition of the

00:11:34.740 dysfunction with movement efficiency that it caused led him to develop specific treatments,

00:11:43.620 both exercise-wise and manual-wise to address those issues.

00:11:48.260 Yanda also had suffered polio as a youngster, didn't he?

00:11:50.820 Yeah. So he had suffered the residual effects, the post-polio type syndrome,

00:11:55.700 and that was probably a motivation for his passion for rehabilitation, his passion for the observation

00:12:07.380 of movement. His colleague, Carl Levitt, also a neurologist, he shared that observation palpation

00:12:16.900 tendency to utilize that for diagnosis and treatment.

00:12:21.220 He specifically focused on joint dysfunction, soft tissue dysfunction, as it related to those upper and

00:12:28.900 lower cross syndromes. So he developed specific mobilization techniques for both the joint and

00:12:35.940 the soft tissues, addressing what they were seeing with those postural habituation and movement

00:12:42.660 dysfunction. The third pioneer, also a neurologist, but also a pediatric neurologist, was Volklav Vojta.

00:12:53.300 His observations observing the ontogenesis or the development of motor function after birth during the

00:13:01.460 first 12 months where the postural foundations are established neurologically,

00:13:06.420 he developed specific tests called postural reactions where he could tell the quality or

00:13:18.500 the health of the maturation of the central nervous system during that period of time. And by doing this,

00:13:26.260 he could assess whether there was pathology or a healthy developing central nervous system.

00:13:32.740 So he developed seven specific postural reaction tests, developed and modified some other ones,

00:13:41.140 utilized primitive reflexes, and just observation, observation of the infant during development

00:13:49.140 to be able to recognize the biological age, meaning the maturation of that central nervous system,

00:13:55.700 as compared to the chronological age.

00:13:58.260 So for example, if you had a six-month-old infant that was moving and reacting like a six-week-old

00:14:05.940 infant, that would be an indication that there was some central nervous system pathology.

00:14:11.940 His focus was on treatment of the cerebral palsy infant and patient, and he was able to utilize

00:14:22.260 that observation, those observation of the postural reactions to recognize early on before it would

00:14:33.700 manifest clinically so that interventions could be taken earlier on to take advantage of the neuroplasticity,

00:14:43.060 the ability of the brain to form motor engrams more efficiently, and work around those central

00:14:51.780 lesions that you see with cerebral palsy. So all three of these founding members or founders of Prague

00:15:01.700 School of Rehabilitation were Professor Kolaj's colleagues, mentors, instructors. They shared patients, they discussed cases,

00:15:14.980 and Pavel Kolaj developed or evolved all that knowledge and experience into what we call dynamic neuromuscular stabilization today.

00:15:27.940 Before Pavel came along, so fast forward, this started in the 50s, but fast forward to

00:15:34.980 the 90s. So the Prague School is well-established. You have these sort of founding fathers, so to speak.

00:15:42.340 What were the applications of the Prague School at that time? How much of it was rehabilitation for

00:15:49.540 for kids with cerebral palsy or rehabilitation for people who were injured versus prehabilitation

00:15:57.140 for athletes? Like, what was the breadth of the applicability of the Prague School?

00:16:01.940 Prague School, it's a group of clinicians. And more of the early 90s, the application was primarily

00:16:11.140 rehabilitation, cerebral palsy, general population. With Pavel, Professor Kolaj, just to go in a little

00:16:20.660 bit of his background, you know, again, he's the head of Prague School of Rehabilitation. He's also head

00:16:27.380 clinician for the Czech Olympic teams and Czech national sports teams, hockey, soccer, men's and women's

00:16:34.740 tennis. He himself was a high-level Olympic-level gymnast. So he's a pediatric physiotherapist as well.

00:16:44.660 His work with those three pioneers, his experience as an athlete, his experience treating cerebral palsy and

00:16:53.540 infants, he took that or started to apply that base of knowledge to the athletic population.

00:17:05.540 And the focus of, and the thinking of these founders of Prague School and Prague School today

00:17:14.980 is the influence of the central nervous system is huge and kind of king as far as facilitating the

00:17:24.660 efficiency of transfer of load throughout that kinematic chain. So early on, the focus was more

00:17:32.180 rehabilitation over multiple populations. But maybe late 90s, early 2000s, Pavel started to

00:17:45.620 apply those teachings to that athletic population.

00:17:48.980 Meaning to an uninjured athletic population or to an injured athletic population?

00:17:54.820 Probably at that time, more of an injured population. Two standout athletes that he was

00:18:03.220 able to work with and able to work with and integrate his concepts and principles of dynamic stability were

00:18:11.220 Jean Lezny. Hopefully I say that right. He was an Olympic javelin thrower, three-time gold medal winner,

00:18:20.900 still holds the record for Javelin 98.48 meters, I believe. And the other one is Jamir Jagr,

00:18:32.500 hockey player, Czech hockey player. He was able to help and work with them, help them rehabilitate from

00:18:40.900 injuries. But then also integrate the concepts and principles of dynamic neuromuscular stabilization to,

00:18:50.020 one, decrease the risk of re-injury. But two, also provide the potential for better performance.

00:18:59.460 And we can talk about specifics of those concepts and principles.

00:19:03.380 Yeah. So we're into the early 2000s where now Pavel's basically taking some of the fundamental

00:19:11.300 principles from the Prague School and creating this new discipline. Let's use each of the words

00:19:16.820 to explain to people what this is. So dynamic, of course, is movement, right? It's not just static,

00:19:22.340 it applies to in motion. Neuromuscular, I think, explains the connection between the nervous system,

00:19:31.220 both the central nervous system and the peripheral nervous system. But really,

00:19:34.340 as you said, an emphasis on the central nervous system and how that connects to the muscular

00:19:39.860 system. So a lot of people, I think, assume that acts of strength are purely muscular and they don't

00:19:45.700 realize the neurologic control of those things. For me personally, the hardest one to explain to an

00:19:53.300 unsuspecting audience is stabilization. Now I have a way that I like to explain it, but I want to hear you

00:19:58.980 go first. Okay. It's important to talk about the utilization of developmental kinesiology

00:20:08.260 as a way to explain posture and explain dynamic stabilization. When we're first born, functionally

00:20:20.100 and structurally, we are immature. So our central nervous system is still maturing. Our bones are still

00:20:26.100 forming. The first weeks of life, first four to six weeks of life, the lower central nervous system

00:20:35.220 structures, the brainstem level is kind of dominant. So primitive reflexes are dominant.

00:20:40.340 Examples of that suck reflex, gag reflex, grasping, you know, obviously being able to blink. I mean,

00:20:48.180 the most primitive reflexes that our species, I mean, we take these for granted.

00:20:52.740 So they help keep us alive during that period of time. So as that central nervous system matures,

00:20:59.300 and if it's maturing in a healthy way, by a three month period of time, actually, let me go back,

00:21:07.380 usually starting maybe eight weeks, we start to facilitate the synergy, coordination, and timing

00:21:16.180 of the deep stabilizing group of musculature. And that's diaphragm, pelvic floor, the entire abdominal

00:21:23.380 wall, the intersegmental spinal musculature that runs throughout the entire spine.

00:21:28.020 All right. I'm going to stop you right here. We are going to talk about these things so much

00:21:31.700 that I want to make sure people understand them. So let's go back to the first one. Everybody's heard

00:21:36.820 of their diaphragm, but let's put some actual metrics to it. It's a dome shaped muscle. It's a

00:21:45.300 striated muscle, but it has kind of a non muscular part as well. But I think what most people don't

00:21:51.540 appreciate is how big it is. Right. And how I can't even remember. It's been, you know, back when I was

00:21:57.300 in school, I had to know every attachment of it. Do you recall how far it attaches down and up

00:22:04.020 on both their ribs and the vertebral bodies? Yeah. So the diaphragm, just think of it like

00:22:08.900 a big parachute or a big sheath of muscle that separates the abdominal cavity from the heart and

00:22:15.460 lungs. The attachments, it has attachments on the lower six ribs, on the back of the xiphoid process,

00:22:24.340 which is a little bone at the end of the sternum. And then also attachments on L1, L2 vertebra. So

00:22:32.500 that's right around the thoracic lumbar junction. So that's just an enormous expanse of attachment,

00:22:38.820 attachments being, you know, where the muscles attach and anchor. And therefore that gives you

00:22:43.780 a sense of what their lever capacity is, what they can actually contract. Right. So that there's those

00:22:50.100 attachments and then there's a central tendon that when the diaphragm activates, so one of the primary

00:22:58.100 functions is respiration. So I go to take a breath in, that diaphragm activates, descends,

00:23:06.580 the central tendon drops, the lungs expand, that change in pressure, you're able to draw air into the

00:23:14.260 lungs. And then there's a recoil of the diaphragm and the air comes out. So there's a primary respiratory

00:23:20.900 function. During the first weeks of development or ontogenesis, which is the study of motor

00:23:26.740 development after birth, it's primary respiratory function. The central nervous system has not

00:23:33.380 matured to the point to create the synergy with within the other deep stabilizing group of musculature

00:23:42.580 to create that fixed point through the trunk and the pelvis.

00:23:45.380 So by around three months period of time, that central nervous system has matured to the point

00:23:52.900 where now the hardwired genetic ingrained motor programs start to manifest themselves. So we start

00:24:02.420 to see this coordinated activity of that deep group of musculature.

00:24:07.860 So we've now, I mean, for me, and I think for many people, a very helpful image is that of a

00:24:14.100 cylinder, the strongest possible cylinder, right, would have a big top, a big bottom and a beautifully

00:24:23.220 symmetric side compartment to it, right? A lousy cylinder would have a tiny little bottom,

00:24:29.220 a big top and a dented middle. So if the diaphragm formulates the top of that cylinder,

00:24:36.180 what makes up the bottom of that cylinder?

00:24:38.100 So the bottom of the cylinder, we're looking at the pelvic floor, which is an area of musculature,

00:24:45.460 basically where the babies come out. And that musculature will coordinate the

00:24:56.820 regulation or management of intra-abdominal pressure that is created with the descending

00:25:03.460 of the diaphragm. So the diaphragm, three main functions, respiration, but there's also obviously

00:25:10.180 this huge postural function where it descends even more and creates an intra-abdominal pressure

00:25:18.020 so that when that pressure is created, the pelvic floor will eccentrically load, meaning

00:25:25.700 musculature is active, but stretches. You can think of it like wind blowing into a sail,

00:25:31.220 where the wind blows into the sail, it opens and activates and then it holds and maintains

00:25:37.380 the pressure. But then at the same time, we have the entire abdominal wall, which consists of the

00:25:43.780 the rectus muscles, our six pack muscles, our oblique musculature, which is musculature that

00:25:51.540 crosses the body, comes up and has attachments onto the thoracic cage or the rib cage.

00:25:56.660 And then a big one called transverse abdominus, which wraps around from the back, the thoracolumbar

00:26:04.980 fascia around to the front. So as that diaphragm descends to facilitate a stabilizing function,

00:26:14.260 that intra-abdominal pressure is created. That musculature reacts to the pressure. There's an

00:26:21.380 eccentric load and then an isometric. And then as we coordinate, so we have respiratory function,

00:26:28.980 postural function, but we have to now coordinate between both respiratory and postural functions.

00:26:37.300 So our central nervous system, our brain needs to manage that pressure to provide enough stability,

00:26:46.020 but also allow the diaphragm to also allow the lungs to expand. This coordination is usually where we see

00:26:55.860 people kind of falling apart. And if they fall apart, they'll tend towards what Yanda saw,

00:27:03.380 which is that over-utilization. So in the lower cross syndrome of the extensor musculature and the

00:27:09.780 flexor musculature, because we lose that synergy of that deep stabilization. And if we lose that synergy

00:27:16.900 and that ability to create that fixed point, then our brains do their jobs, which is to find a way to

00:27:23.620 still move and do tasks that we need to do. But in doing so, we'll go to more of a high threshold or

00:27:31.860 like I described more of a compensatory pattern. So developmentally, that three month period of time

00:27:40.980 is where we ideally will have that synergy coordination and timing of that deep group of

00:27:47.860 musculature that will allow the infant to create a fixed point through the trunk and the pelvis.

00:27:54.340 And then also with that management of that intrapedonal pressure, there's a loading on the

00:28:01.780 front of the spine. And with that loading, we get an uprighting effect throughout the spine.

00:28:08.180 So then the intersegmental spinal musculature are eccentrically loading and managing that

00:28:16.740 pressure against the spine to help with that uprighting effect and that unloading effect.

00:28:21.300 Let's again make sure people know exactly what we mean, because we're going to use the terms a lot.

00:28:26.340 When you talk about eccentrically versus concentrically loading, to me, the easiest

00:28:30.740 way to define it is just using the definitions, right? So a muscle is concentrically loaded when

00:28:34.660 it's getting shorter as it's being loaded. Eccentrically is getting longer as it's being

00:28:39.140 loaded. So for example, a bicep curl, this is the concentric phase of loading. This is the

00:28:46.020 eccentric phase of loading. What a lot of people take for granted is both of those are

00:28:50.980 important. But most people when training tend to emphasize the concentric and don't realize

00:28:57.940 the eccentric. I heard a great story. I think it was actually from Michael Stromsness that when a

00:29:03.300 group of US weightlifters visited a group of Eastern European weightlifters, I don't know,

00:29:07.540 maybe it was even you that told this story. They realized that they were counting reps differently.

00:29:11.860 So the American lifters would consider a rep one is up and down. So that was, they were putting all

00:29:17.940 their effort into the concentric, but then more or less dropping the weight on the way down,

00:29:23.300 not really focusing on the effort to put the weight down. And the Eastern European

00:29:28.900 lifters were doing the opposite, right? They were counting it as two reps. It's up,

00:29:34.340 one, down, two. So it was just as much effort into that eccentric. And it's not to say one is right or

00:29:42.020 wrong because they serve different purposes. Obviously, more emphasis on the eccentric will

00:29:46.180 create more hypertrophy. So there are times that you want both. But again, when you look at,

00:29:51.460 for example, and we'll get to this, I'm sure, but when you look at hip abduction, the importance of

00:29:57.540 being able to eccentrically control that is such an important part of injury prevention. And you can

00:30:03.380 spend all the time in the world working on concentrically doing that. So later today, when we

00:30:07.460 actually do some stuff on the mat, you'll have some exercises to demonstrate that.

00:30:11.620 Yeah. The observation, having knowledge of the developmental kinesiology or the ontogenesis

00:30:18.980 and watching that maturation of the central nervous system. And with that healthy maturation,

00:30:26.500 seeing the synergy of the deep stabilization, providing that fixed point and then allowing

00:30:37.060 efficient transfer of force and load throughout that trunk and pelvis area, what these pioneers,

00:30:45.460 Vojta, Yonda, Levitt, Collage noticed was the importance of the quality, basically training that central

00:30:56.740 nervous system. Because if you can facilitate that ideal stabilization stereotype and synergy,

00:31:04.660 then you provide what Professor Collage calls centration throughout that chain of movement,

00:31:12.500 throughout that kinematic chain. And what he describes centration as is, for example, let's say you have

00:31:19.460 the hip joint, is the ability to maintain an ideal position of the femur and the acetabulum,

00:31:27.300 which is the hip joint, throughout that full range of motion. In order to do that, you need a synergy or a

00:31:34.900 nice interplay between agonist and antagonist, like you described the biceps curl. So an interplay between

00:31:42.740 concentric, eccentric activity of the opposing musculature around the joint to help maintain that position.

00:31:51.700 And if that is compromised throughout any part of that kinematic chain, it's going to affect the quality of

00:31:59.060 centration or transfer of force and load above and below that region. So the quality of that synergy coordination

00:32:09.460 timing of that deep stabilization is what Prague School is focusing on with assessment and with their

00:32:18.660 treatment methods. And this is based out of that observation of developmental kinesiology, which is

00:32:28.500 the neurophysiological aspects of the maturing locomotor system. They utilize that as their definition of

00:32:36.180 dynamic movement, dynamic posture, ideal posture.

00:32:40.420 Let's go back to the three-month-old infant and start talking about what

00:32:45.300 normal developmental milestones are through the lens of DNS, picking it up at three months. So

00:32:51.620 what is a three-month-old infant starting to demonstrate and how is that progressing as they

00:32:56.580 become six months, nine months, a year, et cetera?

00:32:58.580 Right. At three months, with that ability to create that fixed point, now the larger,

00:33:05.700 longer musculature and larger muscle groups have something to anchor off of. So creating that fixed

00:33:14.500 point, for example, allows the infant to now turn their head and fix their gaze. Prior to that, during

00:33:22.020 those first weeks of life, the ability to fix their gaze is not there. By three months providing that

00:33:29.940 stable point, now they can turn, fix their gaze, and now they start to get more of the somatosensory input

00:33:36.100 from the environment, which is going to trigger an external cue or a drive to start to explore.

00:33:46.260 The infant at that period of time can lift their legs out of the base of support. So they can,

00:33:51.860 you'll see a triple flexion, so 90 degrees at the hip, 90 degrees at the knee, neutral position of the

00:33:58.100 ankle joint or subtalar joint. They'll be able to bring their hands together and bring their hands to

00:34:03.700 their mouth. And let's explain what's actually required to do that. Because again, most adults would

00:34:09.940 take that for granted. But what is it neuromuscularly that is being hardwired in that three-month-old

00:34:17.220 infant that is pretty impressive? And when you really stop to think about it, that they're

00:34:22.500 able to bring both legs up, coordinate that movement. And by the way, are they necessarily

00:34:29.860 doing that the way a 50-year-old person would do that if you laid them on their back?

00:34:35.620 Like having now watched a lot of infants, they tend to all kind of do it in a very similar way,

00:34:41.380 whereas adults tend to not do it in a certain way. Neurologically, the coordination and timing

00:34:48.100 of that deep stabilization group of musculature needs to be on point to be able to create a fixed

00:34:55.620 point so that the, again, the larger muscle groups can anchor off that to bring the legs up.

00:35:01.380 Now, the infant has, you know, there's a different thoracic cage size at that point. Their head in

00:35:09.300 relation to their body is bigger. Their limb length is bigger. They're still growing. The bones are still

00:35:17.060 forming. So that's much different than a 50-year-old. Our limb proportions are different. Our mobility is

00:35:24.900 going to be different. So we may have different body proportions, you know, mobility, but we all went

00:35:33.700 through these developmental milestones and most of us develop our central nervous system in a healthy way.

00:35:42.500 So we still have those same motor patterns that our central nervous system is going to want to

00:35:48.740 kick into. Some of the efficiency of accessing those nice stereotypical motor patterns that we're born

00:35:59.620 with can be compromised due to soft tissue, dysfunction, rigidity, lack of range of motion

00:36:08.340 throughout our joints, postural habituation that Yanda described. All that factors into our can override the

00:36:20.420 access to those ideal patterns. What Prague School tries to do is with the specific assessments assess that

00:36:30.740 efficiency of that deep stabilization system, whatever age that we're at, and then utilize specific what

00:36:39.060 we call active exercises, which are based off of the developmental milestones, which we'll get back to in

00:36:44.980 a second, to utilize specific points of support and positioning to help wake up or facilitate those patterns

00:36:54.900 that we still have as adults. So three months of age is the start of that ability to create a sagittal

00:37:03.540 stabilization. Tell people what sagittal means versus coronal. So sagittal is kind of like straight ahead.

00:37:10.980 Frontal plane would be if you're on your side or to the side. And then there's transverse plane,

00:37:18.100 which is think about rotating in the transverse plane. So what happens now as they approach six months of age?

00:37:26.900 Three months, you see the start. Four months, that coordination is usually complete.

00:37:33.300 Four, four and a half months, once they've completed that ideal facilitation of a fixed point,

00:37:40.420 now they start to be able to utilize the oblique slings. And you'll start to see some differentiation

00:37:47.780 in the pelvis and the limbs. And as that synergy gets more and more efficient, which means better,

00:37:56.020 better management of that intradontal pressure, you'll see the hips coming up into higher position,

00:38:02.180 the legs coming up into being able to come up into a higher position. The infant's range of reach will

00:38:10.260 improve as well. At four months, they're able to touch the groin area. At five months, they can reach

00:38:15.540 their knees. At six months, they can reach their feet. And then by seven months, they're bringing the

00:38:22.180 foot to the mouth. And just to be clear, most people would say, is that just a result of increasing

00:38:27.940 flexibility. But really the answer is not so much that they have more flexibility. They were quite

00:38:33.460 flexible at birth. It's more that they now have the motor control and the stability to coordinate

00:38:42.420 something that is everywhere from shoulder to foot or hand to foot, basically.

00:38:48.100 Right. And do it in an efficient manner. So I'm a parent, you're a parent, and you remember when the

00:38:57.540 kids were developing, they get this all the time, they're like, oh, my son was rolling all the way

00:39:03.380 over at three months. That is possible. They can normally, well, not normally, but ideally at that

00:39:11.060 six month period of time, there's enough of that synergy and coordination and timing that the infant,

00:39:17.220 you'll see the infant at that time rolling onto its stomach. Now, they could maybe do it at three

00:39:23.300 months, but they're not going to do it with that coordination and that efficiency of transfer of

00:39:28.900 force and load. You may see them turn and kind of revert back to more of that the newborn posture,

00:39:38.580 meaning they're finding a way to turn. They're using more of a compensatory pattern to make that action

00:39:44.900 happen. Kind of the same thing you see with movement with adults. If the synergy coordination timing of

00:39:55.300 deep stabilization is not on point, they find a way to move. But when they move, as with the first weeks

00:40:05.140 of life, the newborn infant, you'll see anterior pelvic tilt, you see a flaring of the rib cage,

00:40:11.860 the shoulders, you'll see elevation, protraction, reclination or extension through the cervical spine.

00:40:19.380 The newborn, when they look or when they move, the whole body is moving. They don't have that ability

00:40:26.180 to create that fixed point, but they're still able to make movements. As they're going through the

00:40:33.780 developmental milestones with that motivation or that drive to move and explore their environment,

00:40:42.180 they may find ways to reach that toy, but not be creating the ideal centration and stabilization.

00:40:52.260 With the central nervous system maturation, it's not like at three months, four months, six months,

00:40:59.540 boom, they wake up and automatically they're in this perfect synergy coordination timing.

00:41:05.140 As that central nervous system is maturing, there's thousands of trials and errors. They're

00:41:11.060 forming the brain mapping and motor engrams, finding the right points of support

00:41:16.900 as the coordination of the central nervous system is kicking in.

00:41:21.140 So you may see at the beginning of six months and they're turning, maybe they're not able to

00:41:30.740 keep the alignment of the diaphragms during the turning, but they're still able to do it.

00:41:35.300 Maybe by then three weeks into it, now their coordination and timing has become

00:41:42.340 more efficient and better. And they're able to make that turn with a better quality of activation.

00:41:48.820 So how does it go from there? What gets them to crawling and ultimately standing?

00:41:53.300 So what you see with the developmental milestones at three months, we talked about with the newborn,

00:42:00.740 you have more of the lower central nervous system structures are maturing. At three months,

00:42:06.500 we see more maturation in the subcortical region of the central nervous system. And that's where we get

00:42:12.420 the manifestation of these postural foundations. So as that central nervous system matures,

00:42:21.220 certain milestones, three months, four months, five, six, seven, you'll see the infant starting to be

00:42:27.940 able to attain higher, more unstable positions. These developmental milestones are moving towards

00:42:35.460 basically the verticalization process going from either supine on the back or prone

00:42:42.260 and then working their way up trial and error, learning with that healthy central nervous system

00:42:49.860 maturation, where at seven months, they're able to come to their side. Eight months, they come up into

00:42:56.900 what we call a high oblique sit position. Nine months, they're able to crawl. 10, 11 months,

00:43:03.540 you'll see them being able to attain like a kneeling position. 12 months, they're squatting. 13, 14 months,

00:43:11.860 they're standing. And then 14, 16 months, on average, you see the start of ambulation. Now this is

00:43:20.260 variable. Some kids, my son was walking at 10 months. There's maybe 15 months, 16 months. So there's

00:43:28.260 variability within these milestones of where we see the infants. But on average, these specific

00:43:37.620 points, you'll see a specific competency in stability and reaching or moving towards that verticalization

00:43:46.820 process. Now, if you exclude cases of pathology like CP and things like that, where there are injuries

00:43:54.180 that are preventing the neuromuscular development and the achievement of these milestones, is it more

00:44:01.860 or less the case that all kids who are given the fair chance to sort of explore and go about these

00:44:08.580 things naturally will reach a certain age, call it two or three, and they'll be quite healthy from a

00:44:15.780 dynamic and movement standpoint? Like, is it, you know, for example, like yesterday,

00:44:19.780 we spent a bunch of time looking at my three and a half year old and frankly, it's a clinic and

00:44:25.700 movement at that age, right? Is it safe to assume basically all three-year-olds move really, really

00:44:31.780 well? Like they haven't started to get into the habituated movement patterns that will begin to

00:44:37.780 destroy them, right? Yeah. Voita and others talk about usually what they see is around 70% of

00:44:48.180 infants are going to have that healthy central nervous system maturation,

00:44:54.100 go through the first weeks of life, the postural foundations, the three to 12 months, the subcortical,

00:45:02.660 and then from two, four to six years of age, you have more of the cortical maturation where you see

00:45:11.220 fine motor dexterity and movement, you know, ability to write and you see the language develop and you

00:45:19.620 see motor learning. Sorry, the subcortical phase goes till about two?

00:45:24.020 Three to 12 months is where we see these postural foundations. After that, you start to get that

00:45:34.420 cortical integration maturation, but the motor learning and the process, I mean, it's like two

00:45:43.380 to six, but I mean, and beyond. Now, now I'm surprised to hear you say only 70%.

00:45:49.860 Right. And this is, I don't know if I can't say the study, maybe it's their observation.

00:45:56.580 So they, they talk about 70% normal maturation. The other 30%, it's a spectrum. So you'll have on one,

00:46:06.260 one end, the CP child or, you know, the CNS pathology. But then there's this, this spectrum

00:46:14.500 on the other end of the spectrum, Yanda called it minimal brain dysfunction. It's also called central

00:46:21.940 coordination disorder. So there's maybe not that ideal development, but again, there's a spectrum

00:46:32.660 to that. So that may manifest during that, when we see the cortical time of central nervous system

00:46:39.700 maturation, maybe there is learning disabilities or not as efficient movement patterns. And this is

00:46:48.980 something that Prague school, as far as a curriculum, there's a whole pediatrics section during with

00:46:57.140 their curriculum, which they go deeper into that aspect of observation and specific utilization of,

00:47:07.540 of treatment options. Usually with a healthy central nervous system maturation and a good environment for

00:47:16.420 the child to explore the child to explore movement and the variability of movement and do the trial and

00:47:23.540 error and find their ideal points of support, you're going to see this nice, healthy maturation.

00:47:31.380 Things that may compromise that, I mean, we see in modern society and culture, a kid who's in their car

00:47:39.460 seat six hours a day, or maybe doesn't have that environment where they can explore.

00:47:45.700 I think another one that I remember Michael showing with me was when kids are sped up on milestones.

00:47:52.260 So for example, those seats that prematurely prop kids into a seated position.

00:47:58.020 Jumpies.

00:47:58.580 Yeah.

00:47:59.060 Well, even before that, you know, that little Bobby chair where, and again, we're all guilty of this. We

00:48:03.620 stuck our, I know we stuck our kids in these things, at least the first two, because when our third

00:48:08.180 kid came along, I was already interested in DNS. So then he became sort of the observation for DNS.

00:48:13.860 But with our first two, yeah, you're going to stick them in those silly seated chairs and they're,

00:48:18.740 you can't, they don't have the support before they're ready. So they can't even support their

00:48:22.740 own weight. So they're in this slouch position. And then you put them in those things. We called it

00:48:27.300 the circle of neglect. So it's like the thing where, you know, they're standing before they should be

00:48:32.820 standing. So all of these things actually interfere with the normal neuromuscular development.

00:48:39.780 Putting kids in shoes too early probably does a tremendous disservice to them.

00:48:44.180 Right. So I, ideally they're going to have an environment where they're going to figure this

00:48:48.660 out themselves verse, you know, that another one is the little walkers that they'll hold on to and

00:48:55.540 and walk. Ideally, they're going to play with their environment. And with that combination of

00:49:06.340 healthy central nervous system maturation, find those ideal points of support and be able to

00:49:13.700 utilize those motor patterns that are manifested with that healthy central nervous system.

00:49:19.620 So the environment that we, we have children in is key. And this, I mean, you can take this

00:49:30.100 and look at just our society just with as adults. Let's go from, okay, so we can put them in shoes

00:49:37.540 too early, put them in silly sit-up seats in the circle of neglect and give them walkers. And then

00:49:43.220 another huge set of insults come when they go to school, right? Because now they're sitting in chairs

00:49:49.220 for six or seven hours a day. And what does that do for a six or seven year old, which is unfortunately,

00:49:56.020 by the time they're six, they're sort of sitting in chairs six hours a day, at least. So what is that

00:50:00.180 doing to interfere with this process? This is where you start to see the start of that,

00:50:06.500 those postural syndromes. When we get into those sustained seated postures,

00:50:12.500 one of the main things that happens during those developmental milestones with healthy central

00:50:18.180 nervous system maturation is we're able to line, keep alignment or approximation of the pelvic floor

00:50:24.900 and the thoracic diaphragm. The more efficiently that we do that, the more efficiently we manage

00:50:30.020 intra-abdominal pressure and uprighting throughout the spine. And then again, transfer of force and load.

00:50:36.580 If we fall into repetitive postures or postural habituation, which as a society is kind of a

00:50:45.540 bit prevalent, gravity is going to win. No matter how nice the chair is, we're going to start to fall

00:50:52.260 into that slumping posture. And when we get into that slumping posture, the shoulder's coming forward.

00:51:00.500 That is actually going to create an inhibition of the diaphragm's ability to descend. And again,

00:51:09.380 we need that descending of the healthy and ideal descending of the diaphragm for both respiration

00:51:14.980 and stabilization. So if we start getting that descending becomes inhibited due to the postural

00:51:24.340 habitual habituation, our brain's going to find a way to get air to the lungs. So it'll start to kick in

00:51:32.420 the accessory breathing musculature, which is that the sternocleidomastoid, the upper traps,

00:51:39.300 muscles called the scalenes, which attach to your cervical spine and the upper two ribs. You'll see the

00:51:46.500 pec minor also start to help to lift the thoracic cage to help get the expansion to get the air.

00:51:55.780 So again, the brain starts to do its job, which we need air. We're going to use these guys to get

00:52:02.260 the air. And it's a good short term kind of survival strategy. But if we do it often enough,

00:52:09.140 that becomes the go-to pattern. So you'll see a change in respiratory pattern, meaning decrease

00:52:18.100 utilization of full expansion of the diaphragm and more of a pattern of over utilizing the

00:52:24.420 accessory breathing musculature. This can occur quite young. I mean, I think when we, you know,

00:52:28.740 we were joking about it yesterday, but you look at my youngest, I mean, his abdomen is huge.

00:52:35.140 That's obviously an enormous asset to him. You can see it when he breathes. It's his,

00:52:41.140 it's abdominal expansion more than it is thoracic expansion. A child that age, if developing

00:52:47.460 normally is not using any of these accessory respiratory muscles. And there's something about

00:52:53.300 this anchor point being in the abdomen, right? I mean, one of the first things I learned in DNS was

00:53:00.660 how to regain intra-abdominal pressure through eccentric loading of that cylinder.

00:53:08.260 I don't think it had ever been presented to me how important that was because prior to that,

00:53:13.060 any amount of perceived intra-abdominal pressure had been acquired through concentric loading.

00:53:20.180 So for example, when trying to pick up something heavy, you can take two strategies to that. I think,

00:53:26.420 I think most people would agree if you wanted to pick up 300 pounds right now, you must generate

00:53:32.820 pressure in the abdomen. I don't, I don't think anybody would assume that you could pick up 300

00:53:36.980 pounds, which is twice your body weight without generating pressure here, but how you do it matters.

00:53:44.180 So explain those differences. And, and again, either with or without the developmental lens,

00:53:49.140 but I think that the developmental lens is always a great way to think about how kids move.

00:53:55.300 Right. So if you think about developmentally and how that stabilizing stereotype evolves,

00:54:03.940 think of it as a, an inside out strategy. You're creating an intra-abdominal pressure to

00:54:10.020 load the abdominal wall. And then with the loading of the abdominal wall, eccentric, isometric,

00:54:16.180 and then there's this interplay of all that activity, concentric, eccentric, isometric to

00:54:23.300 manage that pressure for whatever tasks that you need to do. So if I'm sitting here and I'm going to

00:54:29.940 pick up that pen, I need some function of stabilization to then move this limb, provide a fixed point for

00:54:38.820 my anterior, posterior slings to provide a nice position for the shoulder girdle to then again,

00:54:45.940 get that synergy throughout the kinematic chain and pick up the pen. So there's a certain amount of

00:54:51.700 management of that intra-abdominal pressure that I need. If I go to the chairs that we're sitting in,

00:54:58.180 that we, we moved earlier, this is a lot more weight. I'm going to need a lot more coordination and

00:55:06.260 management and creation of intra-abdominal pressure to create the fixed point to transfer the ground

00:55:13.700 reactive forces through my lower extremities, through my trunk and pelvis to, you know, my arms holding,

00:55:20.180 holding the chair. So there's more facilitation of that intra-abdominal pressure. So that's what we see

00:55:28.020 developmentally that quality of stabilization. And that stabilization, it's not static, it's, it's,

00:55:36.820 it's dynamic. We should be able to manage that intra-abdominal pressure through full extension,

00:55:42.980 full rotation, full flexion. That's the beauty of that dynamic neuromuscular stability. And that's what

00:55:50.020 we see with our, that quality we see in the high, high level athletes. We can also create stability by

00:55:58.180 bracing. And if you think about bracing, if someone's going to punch me in the stomach, I may go for a

00:56:04.100 concentric. And where the abdominal wall shortens and tightens, I'm still creating a stabilizing function. And I can

00:56:14.020 still use that to move objects or prepare for impact. When it comes to dynamic movement, the inside out

00:56:26.580 strategy and the central nervous system management of that stabilization allows me to create the stability

00:56:35.060 efficiently where I need it, but then also be able to, for example, relax my extremity. So with high

00:56:43.780 level movers, athletes, you see, they'll have nice postural foundations, they also have very nice

00:56:52.340 cortical function or body awareness. So the Fedderers, the Kelly Slaters and surfing, they have that ability

00:57:00.660 to, their movement looks fluid and effortless. So they have that ability to relax and efficiently stabilize where

00:57:08.420 they need to stabilize. Sometimes you need to incorporate that bracing strategy on top of

00:57:17.380 the facilitation of intraminal pressure for excessive loads, where we go beyond our threshold, our

00:57:26.020 functional threshold, meaning our ability to keep that quality of stabilization. When we go beyond that ability,

00:57:34.420 we go into what we call the functional gap. And when we go into the functional gap, that's where we see

00:57:42.900 more of that high threshold strategy, maybe bracing strategy to get the job done, to get that weight up,

00:57:50.020 to maybe kick that ball a little extra harder. Training wise and in athletics, that's where those athletes

00:57:59.220 spend a lot of time because they're always, they're kind of pushing that threshold all the time.

00:58:04.580 So you'll see with athletes, a tendency, if they're spending all their time training, competing in that

00:58:14.100 functional gap beyond the ability to maintain the more efficient transfer of force and load,

00:58:21.860 then that pattern, that high threshold compensatory pattern becomes the, starts to become the norm with

00:58:28.980 everything, picking up the pencil. So one of the things that we try to do, or I try to do as far as with

00:58:37.380 training and rehabilitation, not just with the athletes, but with, you know, the general population

00:58:43.140 is help them facilitate that quality of stabilization. So they can increase that threshold of being able

00:58:50.180 to main, you know, stay within that, that functional threshold or that functional capacity

00:58:56.180 so that when they do have to go into the functional gap and go to those compensatory patterns,

00:59:01.540 it's not all the time.

00:59:03.860 Let's talk about an elite athlete. And again, I think the thing with the really,

00:59:07.060 the most elite is they don't have to train in DNS. A lot of them are just doing this naturally. I mean,

00:59:13.380 that's sort of what makes Roger Federer great. And one of the hallmarks of that greatness is injury

00:59:18.420 prevention. It's not just the greatness at what they do. It's the longevity with which they can do it.

00:59:24.580 Yes. So when I lecture, I use Federer as an example, you know, you look at his career,

00:59:31.540 just longevity and injury-wise when he has been injured, but you usually see a quick recovery.

00:59:39.780 Going back to Jager and Jalejny, Jalejny had a 20-year career in javelin, which I don't think is

00:59:47.860 very common. Jager is 48. He's still playing. With Jager and Jalejny, Pavel working with them,

00:59:56.580 the emphasis was on the awareness, the facilitation of this ideal stabilizing pattern,

01:00:03.780 the timing of movement, the centration throughout the kinematic chain. And then with that, the ability

01:00:11.060 to, we call it, differentiate within, for example, the pelvis over that, that femoral head. So the

01:00:17.460 focus was with them was the quality over quantity, I guess you can say.

01:00:23.300 What percentage of his time do you think, because obviously Federer has just an unbelievable

01:00:28.980 functional capacity. How often do you think he is in excess of that, in that gap zone where he is

01:00:35.700 using compensatory movements that are putting long-term stability at risk?

01:00:41.460 So I think when you see those athletes that rise to the top, you watch Federer, for example,

01:00:48.020 you see the creating the point of support, the positioning, the alignment of everything,

01:00:54.020 he's creating naturally that centration and that transfer of force and load. There is times,

01:00:59.700 maybe he gets out of position or a little extra hard where he's going to go into that functional gap.

01:01:04.180 He's naturally has a functional, huge functional capacity where he can maintain that.

01:01:09.380 I think with him, you also, and this goes to training, he has a good team. He has trainers that

01:01:21.060 are programming certain things in a way and giving him certain things so that he can still facilitate

01:01:29.380 that quality of movement and build strength capacity on top of that. One thing that I see,

01:01:36.500 for example, out on the PGA Tour, I'll see players that have good programs, good coaching,

01:01:47.140 they'll tend to stay within that functional capacity. They're still pushing it and still,

01:01:53.460 you know, with them, it's just repetitive motion, which postural habituation, repetitive motion,

01:01:59.460 injury are things that compromise that synergy and coordination of that dynamic stability.

01:02:05.220 So if you have good programming, dosing, loading, timing, recovery, and on top of that,

01:02:14.980 you have amazing, you know, potty awareness and cortical function, you're going to see longevity and

01:02:20.820 you're going to see nice quality of movement. What I see on the other end is players, athletes,

01:02:29.860 poor training programs, over training, spending too much time in the functional gap,

01:02:39.380 falling into what my colleague Rich Ulm talks about, the extensor compression syndrome,

01:02:45.380 which you see a lot with lifting with the power athletes, which he works with a lot of.

01:02:51.300 And then you see, when you have that reliance on that higher threshold, you see more incidents of injury,

01:02:59.620 longer recovery, versus the opposite, the fetters. Yeah, they get injured, but they recover fairly

01:03:07.860 quickly. And that's what you see, again, Jagr and Jelezny are nice examples of that. Both

01:03:14.500 checks and Pavel working with them over this 20-year period of time, integrating and putting in his ideas

01:03:26.420 and his experience with everything that we talked about with those rehabilitation pioneers into these

01:03:33.220 athletes, kind of like a test subject, so to speak. So now Prague School and DNS practitioners

01:03:43.220 that's what we're trying to help integrate with our athletes, with the general population.

01:03:49.540 What percentage of people that you work with are coming with an injury and therefore in need of

01:03:55.460 rehabilitation where you're now applying DNS to presumably go back to, hey, this is where the

01:04:03.220 breakdown was. Let's go back to where that breakdown would have occurred developmentally and go

01:04:09.300 back and rebuild those steps. So you're going to learn how to stabilize your neck or stabilize your

01:04:15.220 head using the stabilizing muscles appropriately. You're going to learn how to generate concentric

01:04:20.180 intra-abdominal pressure, and you're going to learn how to centrate ipsilaterally and contralaterally

01:04:25.540 and all of these things. And then what percentage of your patients are not coming with an injury,

01:04:31.540 but are coming for performance enhancement and saying,

01:04:34.340 You know, I just can't throw this fastball any faster than 89 miles per hour.

01:04:40.180 And the only way I'm going to get that faster is if I can create a better whip

01:04:44.820 between my right hand and my left leg and hip. You know, so those are two ends of the spectrum.

01:04:52.820 And how do you spend your time on those?

01:04:54.500 The majority of people are coming to me because pain and injury. What happens, especially with the

01:05:01.460 athletes, once we address that, once we calm down, whether it's if it's an acute or chronic injury,

01:05:08.340 we decrease pain and utilize the there's different manual methods within DNS and then integrating

01:05:19.140 the exercises that are based off of those developmental milestones. Once they get to a certain point,

01:05:25.700 ideally, I'm going to work with a trainer or with the coach. And hopefully they're on the same

01:05:34.020 mindset so that they can then progress to the strength training, to the specific technique.

01:05:41.940 More and more, these athletes are, you know, it's a combination of once they're out of pain,

01:05:51.620 we work with the quality of stabilization and movement and transfer of force and load.

01:05:57.940 Let's take a group of, let's say a hundred athletes who come to you in pain.

01:06:02.980 Again, just looking for rough numbers, what percentage of them will buy into the thesis of

01:06:09.620 this very non-traditional way of rehabilitating is going to help? What percentage of that of that

01:06:16.500 hundred will stay with the program to get better? Not enough.

01:06:19.860 So what's the number? 10, 20% maybe. That's it. Yeah.

01:06:24.660 What I see happening, you know, for example, Major League Baseball is integrating DNS more and more.

01:06:32.420 So in San Diego with the Padres, I've started to consult with them a bit. There's a hitting coach

01:06:40.500 for the Dodgers that comes in and we kind of workshop ideas where he's integrating the DNS

01:06:48.980 concepts and principles. So it's starting to get recognized more for that value as far as

01:06:56.820 the performance enhancement aspects of it. Culturally within sport, what I see, especially in the West,

01:07:05.300 they want numbers, they want what's their lift, you know, what's their strength capacity,

01:07:11.540 which is important. But I think it's also important to, again, integrate those two,

01:07:19.140 the quality of movement and stability, and then increasing that, their strength thresholds.

01:07:25.780 But even just with an injury. So if you, let's just say a hundred athletes that are,

01:07:28.980 you know, let's say gymnasts and hockey players and football players that come in with lower back pain,

01:07:34.020 you're saying only 20 of those would stick with the program until they got better. 80 of them would

01:07:41.300 abandon the program before they improved.

01:07:43.780 A lot of times and just across the patient population, a lot of times once, once people

01:07:48.820 are out of pain, it's kind of out of sight, out of mind, they go back, they go back into their,

01:07:54.580 that's what I'm trying to differentiate, which is how many of them just stick with it a long

01:07:58.500 enough to get out of pain. The next question I'm going to ask is once out of pain, how many of them

01:08:03.940 stick with the program and switch basically from rehab to prehab?

01:08:08.660 Going back to that, one of my goals, especially with the athlete, once they're out of pain,

01:08:14.660 we develop a prehabilitation kind of program. And we utilize those, again, going back to the knowledge

01:08:25.380 of developmental kinesiology and developmental milestones, which later we'll actually go through.

01:08:31.060 So based on what I'm seeing with their insufficiencies and with the insufficiency of

01:08:38.340 that coordination of stabilization, I will give them certain things, certain sequences

01:08:45.780 of movements and exercises that they practice with awareness to facilitate better strategy for

01:08:54.820 stability. And then that's part of their movement preparation or prehabilitation before, whether

01:09:04.740 it's their strength training or their technique training or going out and performing. That's a

01:09:13.140 larger percentage because that's part of what I kind of program into the rehabilitation. So some athletes

01:09:23.060 will get that and they're okay, great. This is good. I'm going to go do it. And then occasionally

01:09:30.100 they're coming back and getting, maybe we're adding to it based on what, how they're functioning. Now

01:09:37.700 other athletes, they want more. And that's that smaller percentage. Part of it too, probably access,

01:09:45.620 you know, and availability as far as being able to be in San Diego and working one-on-one with me.

01:09:52.660 So there's different factors that will tie into how much they're doing. But within the whole

01:10:02.180 treatment protocol or rehabilitation protocol, I'm giving them things that they should then

01:10:08.100 integrate into their programs. What is the most common chief complaint of a person that walks into

01:10:14.180 your office? Is it lower back pain? That would be my guess. Yeah. Majority is low back. Okay. So what are

01:10:21.220 the most common causes of lower back pain that you see? Across the board, if they're suffering from

01:10:31.060 low back pain, whether it's acute or chronic, usually there's an underlying pattern of that lack of,

01:10:40.820 or the inefficient activation of the deep stabilizing system and more of a tendency towards

01:10:49.380 that extension compression activation, that over activation of flexor extensor. Explain what that

01:10:56.900 means in a bit more detail, given the ubiquity of this injury and the probability that 80% of the

01:11:03.540 people listening to this have already experienced back pain or will experience back pain in their

01:11:08.660 lives. I want to make sure if people take nothing away from this podcast, they understand the etiology

01:11:14.020 of lower back pain. Unless you've had a, let's say a car accident or a fall, that's like an acute injury.

01:11:22.740 That can be a cause of low back pain. The majority that I see, it's more of a chronic overload over time

01:11:34.180 that if we have that strategy of too much flexor extensor activity, which compromises the positioning of

01:11:45.220 the intersegmental, the joints and the transfer of force and load, then with the compensatory pattern,

01:11:51.860 we'll see more of a hinging in through that lumbar sacral region. And with that hinging

01:11:58.900 over time, you know, it's like, if you keep bending a spoon, it's going to break, you weaken the

01:12:05.620 structure. But yeah, let's talk about the actual anatomy. And I, yesterday I said,

01:12:10.100 I wished I'd brought a skeleton. So the sacrum is a, is basically a single bone. It's actually fused.

01:12:15.940 So it, at one point it was multiple bones. Right. So you have this sort of one fused

01:12:20.980 sacrum and then you have these five lumbar discs numbered one through five. Now between each of those

01:12:28.980 lumbar vertebral bodies is a disc. And then there's one between the fifth lumbar vertebral

01:12:36.100 body and the sacrum. So we refer to them as, you know, L3, L4 is the disc between three and four and

01:12:43.540 L5, S1 is the disc between there. Behind each of these vertebral bodies. So these, these vertebral

01:12:49.060 bodies are sort of held in place by the discs, but then also by the facet joints that run behind them.

01:12:56.100 And it's really difficult to show this. We'll probably have to pull up some images to make this

01:13:00.340 easier for people to see, but the facet joints and then sort of the lamina, which are these,

01:13:06.020 those sort of longer bones hold it all together, but they don't really provide this support. I think

01:13:10.580 the support is probably at the facet joints and at the disc interface. Is that probably fair?

01:13:15.620 Yeah. And then think of all the musculature as the scaffolding and the, you know, the levers and

01:13:22.260 that help with that stabilization. And then the, the activation of that deep stabilization as an

01:13:28.660 uprighting effect. And let's talk about which muscles are on the front of that. So if you were

01:13:33.540 to cut me open here and let's just say you pull everything out of the way. So you pull my bowel

01:13:39.700 out of the way, you pull everything and you go right down onto my spine. What are the muscles you're

01:13:44.820 going to see that are attached to the anterior or front portion of my vertebral bodies? Two main ones

01:13:52.100 that we can talk about is the psoas, which attaches to those transverse processes of the lumbar spine,

01:14:01.220 and then the quadratus lumborum, which also attaches to those processes. Both of those with those

01:14:09.140 attachments, they also come up and they attach right where the, the diaphragm attaches, the crura of the,

01:14:15.140 the diaphragm. So, you know, if you, and again, maybe you can pull up those images and put it on the show

01:14:21.780 notes. So you see all those kind of coalescing in that thoracic lumbar region. If I have that ideal

01:14:30.660 activation of that descending of the diaphragm and the facilitation of that intra-abdominal pressure,

01:14:36.420 that pressure again, loads the, the, the abdominal wall and creates that fixed point that the psoas

01:14:45.780 and the quadratus are anchoring off of. If that's compromised, they don't have anything to anchor off

01:14:54.340 of. And then you see that excessive extension and that overload of those facet joints.

01:15:01.300 Exaggerate what the extension posture looks like so people can see it.

01:15:04.900 So your hips will move forward. If you picture your pelvis as a bowl, you're tipping the bowl

01:15:12.100 forward. Tipping the bowl forward. And then if you think of your rib cage, rib cage is coming forward

01:15:17.460 as well. So your spine, which normally has a bend in it, gets more of a bend in it. Excessive. Yeah.

01:15:24.020 Yeah. And with that oblique position of the diaphragm and the pelvic floor,

01:15:32.420 now there's a mechanical disadvantage of the abdominal wall. So we took a cylinder that's

01:15:38.020 supposed to sit like this and we made it go like this. And we put it like that. So now the tendency

01:15:43.940 is going to be the extensor over activity and the flexor, the psoas. So now you're just getting this

01:15:50.900 repetitive compression on those facet joints. And the disc is getting this repetitive

01:15:57.700 hinging flexion. And then in the center of the disc, we have the fluid or the nucleus working its way

01:16:06.580 through those anterior fibers as they weaken. And then that's where you get the disc protrusions or

01:16:12.980 substance can leak out and the body will go into that, that spas, that protective spasm.

01:16:19.220 You'll see the disc injury, but then you also see over time, facet hypertrophy. So the degenerative

01:16:28.180 changes and the accumulation of bony material trying to help stabilize. So part of my story and

01:16:37.140 kind of discovering what drove me into utilizing DNS, discovering Prague School, I developed what was

01:16:45.620 called the spondylolisis, which is a stress fracture in the spine, part of the pars, which is kind of

01:16:54.020 that arch that attaches the vertebra and then to the facet joints. So for me, with overtraining, poor

01:17:04.180 recovery, poor postural foundations, I was premature. And looking back, knowing what I know now,

01:17:15.140 looking at pictures or videos of myself, I could see that, that compensatory pattern.

01:17:21.300 It didn't catch up to me till college, you know, especially as we're younger, we have a huge ability

01:17:26.820 to compensate and we can get away with stuff. But in college, it caught up to me with that stress

01:17:32.500 fracture. So I was kind of like the poster boy of upper and lower cross syndrome and lack of efficient,

01:17:40.180 stabilizing, stabilizing strategy. I had plenty of motivation and drive and practice, you know,

01:17:47.140 hour upon hour. But at a certain point, structure overload of in that, for me, L4, L5 region,

01:17:57.860 that gave way. And when that gave way, then I went into this whole chronic pain cycle. And it wasn't

01:18:05.860 until I went orthopedist, physical therapist, chiropractic, all of them helped in their own way.

01:18:13.540 But it was, I knew there was something missing. So probably for selfish reasons, I went into this

01:18:21.060 profession trying to figure out my own pain and try to figure out how to recover.

01:18:25.700 And in medical school, same chiropractic school, first year, you're just getting bombarded with all

01:18:32.340 anatomy, physiology, functional biomechanics. All of it was amazing and interesting, but I'm like,

01:18:38.500 this isn't helping me. It wasn't until the second year where I was introduced to Prague School,

01:18:46.740 Yanda and Levitt and what they were teaching. It was like, oh, finally, something made sense.

01:18:53.540 And just intuitively, it made sense to what I was dealing with. So I started to learn more and more

01:18:59.940 about that while I was in school, incorporating some of the treatment methods and the exercises.

01:19:06.260 And that got me further along of kind of pulling myself out of my own kind of chronic pain.

01:19:14.020 And then once I was out of school, 97, 98, after a few years, there was a clinician,

01:19:22.980 Dr. Liebenson taking small groups over to Prague to learn from those pioneers and those Prague therapists.

01:19:31.620 So I was able to go over there. It was like an eight day intensive kind of lectures and workshops,

01:19:40.580 got to see Levitt. But unfortunately, the year before, Yanda had passed away. And I believe

01:19:47.540 Voeta passed away, I think early 2000, 2001. But that was my first introduction to

01:19:58.340 Professor Pavel Kolaj. And at that time, it was his ideas talking about developmental kinesiology

01:20:06.260 and then utilizing that knowledge to develop the assessments and the treatment strategies,

01:20:14.340 not only to the cerebral palsy population, but then he was talking about the adults and then the sports

01:20:21.540 population. So once I saw that, again, that was like another light bulb and another piece of that puzzle

01:20:28.820 for me to work my way out of it, out of my own situation. And then from 2003, basically,

01:20:36.500 I've watched this evolution of DNS, the concepts and principles turn into the actual name and then

01:20:43.300 the curriculum of where we're at now. Now, you're quite senior within the sort of international

01:20:49.780 community of DNS. You're one of only 18 international instructors. Isn't that about right?

01:20:55.860 Yeah. Yeah. What are the different levels of certification within DNS, the highest level

01:21:01.220 being where you're at? Can anybody attain that level? Or do you have to be a chiropractor,

01:21:07.620 a physician or an osteopathic physician? Like what are the... Yeah. So there's three tracks of the

01:21:15.860 dynamic neuromuscular stabilization curriculum. One is a clinical track. It's a DNS A, B, and C.

01:21:23.620 And then the fourth course is a D course, which you actually go to Prague and it's like an intensive

01:21:30.980 with the Prague therapists. There's a specific exercise sport sequence of courses. There's three

01:21:40.420 courses there. The first one is focused in clinicians only type of thing. The second one

01:21:47.780 is designed for trainers as well as clinicians, because ideally we design that one because we

01:21:56.340 want the two populations working together and on the same page, but it's a little more focused towards

01:22:03.300 less manual and more of what, how you can integrate it into a training program. The third is pediatrics,

01:22:10.500 where you're going to utilize the DNS handling skills with infants. And that's a series of,

01:22:17.460 I believe, three courses with the fourth culminating in Prague. So that curriculum, I believe,

01:22:27.460 started to come about 2009. And then off of that, we have specialty courses where we integrate different

01:22:38.180 things. One of Prague schools goals, it's, you know, they don't want DNS to be a, this is a DNS technique.

01:22:46.500 These are concepts and principles that Professor Kolaj, building on those founders and his experience and

01:22:55.940 his ideas, it's meant to be integrated into everything else. Because it can, that's one thing I love about it is

01:23:05.220 you can easily integrate it into the good work that you're already doing, whether you're a trainer,

01:23:10.260 whether you're a clinician and you do a specific technique. You know, for example, the Prague school

01:23:15.380 therapists, they do visceral mobilization, they have specific soft tissue and mobilization techniques,

01:23:23.060 and they're constantly exploring and trying to evolve the teaching and the integration.

01:23:29.300 So it's a, a nice knowledge base and skillset to have, again, to enhance what you're already doing.

01:23:42.180 This afternoon, we're going to go down and actually demonstrate a lot of this stuff by video,

01:23:46.340 because I think that it's really challenging to talk about this stuff. It's just not that amenable to

01:23:53.220 a discussion. It really has to be shown. And frankly, even showing it is challenging. I think

01:23:59.700 experiencing it is the gold standard. That's the ultimate. It's not just movements. It's not just

01:24:06.420 specific exercises, but it's facilitating the awareness of the ideal stabilization and the support.

01:24:14.500 Um, and then with my patients or whether it's training, I want my patients or my athletes to

01:24:23.780 feel that synergy and feel that ability to stabilize where they need to, but then also relax where they

01:24:31.620 need to. So there's a little bit of a process. It's not a cookie cutter thing, like just do this,

01:24:37.780 this, this, this, this, you have to put some work into it. You have to practice it both as a patient

01:24:44.180 and as a clinician or trainer. And I guess that would be, you know, maybe one of the drawbacks for

01:24:52.180 people is everything out there, people are doing, doing good work and trying to help people.

01:24:59.940 And if they have something that's working for them and we introduce these concepts and principles

01:25:04.900 and they're not easily integrated, then maybe they don't, they don't adapt them or they'll

01:25:10.420 adapt a portion of them, which is, you know, fine as well. But it's, it's something that

01:25:17.060 in the curriculum, you know, we try to emphasize the, the need for

01:25:23.300 feeling and practicing the, the movements that we can show later.

01:25:28.500 I mean, I can only speak for myself, but I wonder if my generalization is correct. I think

01:25:35.460 my guess would be that the people who come to DNS late in life with an injury, get better,

01:25:42.260 but then stick with it are probably people who like to really tinker with things and like to toil away

01:25:49.300 and don't necessarily need quick results, but can sort of anchor to a philosophy.

01:25:55.860 They sort of have faith in it and then they can sort of keep pursuing it because a, it feels a lot

01:26:01.140 of the time like you're not doing much. And I think for someone who's used to being quite

01:26:06.740 impatient with, I want results today and Hey, I just started CrossFit. And two days later,

01:26:11.940 I'm doing power cleans. Like this is awesome. If that's the dopamine surge that a person needs,

01:26:16.900 they're going to, I think they're going to struggle with a system where you might spend a week

01:26:22.260 daily practicing, learning how to breathe again. And you'll never stop practicing that,

01:26:27.060 by the way, you'll never stop practicing a really great breathing pattern and a really great pattern

01:26:32.580 of accessing these deep stabilizing muscles we've spoken about and practicing all of these infant

01:26:37.620 like movements. And yes, it gets more challenging over time. And you do these flows that become

01:26:42.660 quite enjoyable and can be very challenging. I mean, most of these things I still can't even do

01:26:48.180 actually, especially with weight. But I don't know, I guess I would say, I always think of things

01:26:53.620 in medicine through the lens of efficacy and effectiveness. So efficacy is how well does something

01:27:00.260 work if it's adhered to correctly? Effectiveness is if you just throw it out in the real world,

01:27:08.340 how well does it work? To me, DNS might be the single most efficacious thing I have ever come across

01:27:16.740 as far as healing injury and preventing injury. I'm not sure if it's the most effective thing,

01:27:25.460 which is not a knock on it. But the point is, to your point earlier, a lot of people aren't going to

01:27:30.340 do it, you know, especially once you get them out of pain, they're not going to want to stay with it.

01:27:34.420 Now, I don't know why that is, but that's the thing that I would hope that DNS can improve

01:27:41.380 upon in the next decade. It's only a decade old, but it's like, how do we take this thing that is

01:27:46.580 so efficacious? Again, meaning if a person actually does it, they're going to get better.

01:27:52.260 It's almost impossible not to fix back pain, neck pain, shoulder pain, like all of these injuries,

01:28:00.340 they're going to get better. We want 90% of people to be able to stick to it once they start.

01:28:06.420 Right. Part of that is with the curriculum, whether you're a clinician or a trainer,

01:28:14.580 part of the process is with the assessment, you're training your eye, just like a good coach

01:28:21.700 will recognize something not right with the runner or the tennis player or the golf swing. DNS will have

01:28:30.660 the specific assessment and those specific exercises based off of development. Once you develop your eye,

01:28:36.180 and recognize where the insufficiencies are, you can recognize that insufficiency of stability within

01:28:43.700 the swing, within the running, within the lift. So in my opinion, you can get to the point where you

01:28:51.620 can utilize these concepts and principles, communicate them in a way, you know, to the deadlift or to the

01:28:59.060 runner where you can help them in that manner. Maybe they're not doing the specific developmental

01:29:05.860 movement, but you're giving them ideas as far as loading, cueing that will facilitate that

01:29:13.060 efficiency. And that's the challenge you're dealing with in major league baseball is you know that

01:29:18.500 there's a way to get an extra four miles an hour out of a pitch, but you also know that that athlete

01:29:23.780 probably doesn't want to, or doesn't have the time to maybe, I would argue they should have the time

01:29:28.180 to, but maybe doesn't want to go back and do all of the fundamental movements and master what an infant

01:29:34.580 does. So now your challenge is while you're on the pitching mound, how do I put a principle in you

01:29:41.380 that's going to create a little more whip like stability? Right. Part of that is training up the staff

01:29:48.020 that will be dealing with that athlete full, full time. The more skilled and movement towards mastery of

01:29:57.220 that, the better it's going to be for the people that they work with. So part of that is that process,

01:30:04.020 that education, that learning process. That's what I see, you know, people starting to ask for,

01:30:12.020 to help with. Because a lot of people will take the coursework and they're like, oh man,

01:30:16.500 yeah, that's awesome. How do I integrate it? And that's also part of the curriculum. We've created

01:30:25.940 specialty courses. So for example, there's certain expertise within Prague School. We have a Prague

01:30:32.660 therapist that focuses on the running athlete. We have one of the instructors dance professionally. So

01:30:40.180 we have a, you know, a dance specific exercise sport course. We've done golf, we've done baseball. Dr.

01:30:50.580 Ohm has a strength specific lifting specific course talking about that integration. So we're trying to

01:30:59.460 create that curriculum to help with that integration. Because if we just have the standard courses,

01:31:07.060 more of that's going to tend to be clinical. But if we show how to actually do the integration within

01:31:14.100 the specialty course, whoever's working with those athletes or an athlete themselves,

01:31:20.260 that's going to be, we're going to be able to communicate it better because they understand

01:31:24.100 that sport. We've even done hockey specific. One of the Czech therapists works with the

01:31:30.100 national, Czech national hockey team. So obviously huge experience. And then we show the integration. So

01:31:38.580 that's part of that evolution of trying to communicate these concepts and principles better,

01:31:47.700 help people integrate them better so that we can, again, enhance what we're doing with our patients and

01:31:54.580 with our athletes or with our people that want to focus on performance.

01:32:00.020 Well, Michael, this has been, this has been interesting. And I think it's going to get a lot

01:32:02.820 more interesting when we, when we go and roll around on the mats a little bit, and I think give a

01:32:07.220 little bit more of a visual explanation of what a lot of this stuff looks like. So thanks so much for

01:32:11.380 sharing your insights and keeping up the fight. Thank you. That went faster than I thought. And I just feel

01:32:16.500 like we scratched the surface. So looking forward to showing it to help people understand it a little

01:32:23.700 bit better. Thank you. Yeah. And hopefully once people see it, they'll want to take that next step,

01:32:28.740 which is feeling it. And I truly think that only when you feel this, do you understand it. And I

01:32:33.540 think that's true of not just DNS. I think that's true of PRI and FRC and all these other things that

01:32:37.940 we've spoken about that in my mind all have a place in both the world of rehab and prehab.

01:32:43.300 Yeah. If you, if you can feel it, then you can start to integrate it and create that new pattern.

01:32:51.620 So thank you. Thank you for listening to this week's episode of the drive. If you're interested

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01:35:29.280 Also,

01:35:31.280 just a couple more battles in the plus one can ano. I also do a similar project's technology that Gracias

01:35:32.080 leme phonologicalты's prevention, and a handful ofů among the pros of my clients.

01:35:33.280 And the he lists criticize between theunu and the plan. I include an email and answer the response

01:35:38.060 of the tool that is a type of client-based tool. Group Divupiorment

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01:35:39.900 really putting things in place in place where I keep going. I think you know we're definitely not going up!

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01:35:41.700 A couple of minutes let's learn about where I have to add more knowledge in

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01:35:46.900 in November 2021!

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The Peter Attia Drive - March 08, 2021

#152 - Michael Rintala, D.C.： Principles of Dynamic Neuromuscular Stabilization (DNS)

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