5 DNSA Treatment PDF

www.rehabps.com 06.12.
16
Dynamic
Neuromuscular MANUAL THERAPY
Stabilization ®
1. Soft tissue techniques

§ Release pectoral and thoracic fascia
according to Kolář
§ Release intercostal spaces
§ Release postero-lateral aspects of abdominal wall
TREATMENT OF THE §
§
Release
Release
auxiliary respiratory muscles
abdominal wall
INTEGRATED SPINAL STABILIZING SYSTEM: 2. Mobilization
§ Spine
DNS THERAPY § Ribs
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ACHIEVE NEUTRAL POSITION OF THE CHEST

IAP DISTRIBUTION WITH CORRECT
ACTIVATION OF DIAPHRAGM
Flared ribs Correct position
Manual contact Thera-Band

§ Abdominal wall § Breathing against the
resistance
IAP DISTRIBUTION WITH CORRECT IAP DISTRIBUTION WITH CORRECT

ACTIVATION OF DIAPHRAGM ACTIVATION OF DIAPHRAGM
§ Eccentric contraction and
§ Physiological movement
ideal tone of abdominals,
of diaphragm must be part paraspinals, QLs, serrati
of any movement and post. inf.
exercise
§ IAP equally increases in all
§ Centrum tendineum
directions
descends down
§ Abdominal organs are
§ Lower ribs spread out pushed caudally
Dynamic Neuromuscular Stabilization 1

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PRINCIPLES OF DNS TREATMENT PRINCIPLES OF DNS TREATMENT

Critical component of DNS concept § Well centrated support
§ All joint centration
§ Active exercise addresses not only muscles, but also the
CNS (BRAIN EDUCATION) § Muscle coordination and balance
§ The movement must be slow to promote awareness of § Spine uprighting
the movement (BODY AWARENESS) § Correct respiration
§ Quality of the movement more important than Quantity § Resistance must be adequate to level of quality and
stabilization
§ Patient must be able to distinguish
§ The resistance must be adequate to the weakest
between correct and incorrect performance segmental link of stabilizing system
§ DNS exercises must be integrated into ADL § Micro-progression in loading
§ Adequate progression (from stabile to more unstable
position)
EXERCISE AGAINST RESISTANCE EXERCISE AGAINST RESISTANCE

Planned = Anticipatory movement is resisted! Planned = Anticipatory movement is resisted!
Stepping forward Arm Stepping forward Leg
§ Shoulder: FL, ABD, ER § Hip: FL, ABD, ER
§ Elbow: Semi-FLEX
§ Knee: FLEX
§ Forearm: from PRO to SUP
§ Foot: PRON, more towards DF
§ Wrist: Radial deviation, MTC ABD, grasp-like position
Supporting Leg
§ Supporting Arm
§ Hip: Towards - EXT, ADD, IR+ ER activity
§ Shoulder: Towards - EXT, ADD, IR
§ Elbow: held Semi-FLEX § Knee: Towards EXT
§ Forearm: PRON § Foot: SUP more towards PF
§ Wrist: Radial deviation, MTC ABD, grasp-like position § These are movements you may resist during
active exercise
PRINCIPLES OF DNS TREATMENT 1.TO IMPROVE THE SAGITTAL STABILIZATION

Sagittal stabilization ensures: § Manual release of rigid
segments which impede
1. Centration of segments (focusing on support neutral initial position (joint
mobilizations, soft tissues
points) technics,etc):
§ C, T, L spine
2. Differentiation of muscle function within the § Chest
global motor patterns: § Pelvis
§ Stepping forward or supporting function § Providing balanced muscle
§ In ipsi- or contra-lateral patterns activity of trunk stabilizers

2. TO IMPROVE THE JOINT CENTRATION 3.DIFFERENTIATION OF FUNCTIONS IN

§ Focus on global parameters GLOBAL MOTOR PATTERNS
§ Crucial is centrated positions § According to key problem find the ideal position
of the chest, spine and pelvis § in ipsi or contra lateral pattern
§ Local parameters influenced
manually by:
§ Approximation
§ Distraction
§ Correct support
§ Active approach
§ Balanced muscle coactivation
§ Active proper support
§ in closed or open kinetic chain

DNS TREATMENT
DNS TREATMENT
Exercise is provided :
§ In static initial position We can use:
§ Movement
§ Just the movement of § Locomotion phases,
the phasic extremity (the transition phases
initiation of the mvt OR § Initiation of movement
whole ROM)
§ Whole range of transition
§ Assisted or leaded mvt
§ Mvt imagery is required § Forwards
§ Resisted movements § Backwards
(against gravity, T band,
weight, Kettle Bell)
THERAPY AND ACTIVE EXERCISE ACTIVE EXERCISE TO ACHIEVE

1. Manual treatment SAGITTAL STABILIZATION
§ Release of the ribcage and pelvis
§ Release of the abdominal wall and e.spinae § Activation of lower
abdominal wall, especially
2. IAP distribution with correct activation of medio-caudally from ASIS
diaphragm
3. Active exercise to achieve sagittal Instruction
stabilization § Inhale as far as above the
groin, increase the IAP
adequately
§ Exhale and maintain that
relative expansion of
abdominal wall

ACTIVE EXERCISE TO ACHIEVE SAGITTAL

STABILIZATION
BEFORE INSTRUCTION AFTER INSTRUCTION
Goal § First with legs supported
§ Spine axially elongated
§ Chest in expiratory
position
§ Parallel position of
diaphragm and pelvic
floor § Later without legs support
§ Equal distribution of IAP
independent on
respiration
§ Equal activation of
abdominal wall
VARIATIONS OF ACTIVE EXERCISES ARM FLEX/EXT – OPEN KINETIC CHAIN (OKC)

§ Movement of extremities against resistance
§ C-spine flexion without chin poke § Sagittal stabilization
§ During any movement of extremities/head sagittal § Isolated movement in glenohumeral joints
stabilization must be established independently
on respiration (humerus is moving in glenoid cavity)
LEG FLEX/EXT – OPEN KINEMATIC CHAIN LEG FLEX/EXT – OPEN KINEMATIC CHAIN
(OKC) (OKC)
§ Sagittal stabilization § Sagittal stabilization
§ Isolated motion in the hip § Isolated motion in the hip
(femur is moving in acetabulum) (femur is moving in acetabulum)

VARIATIONS OF ACTIVE EXERCISES VARIATIONS OF ACTIVE EXERCISES

Isolated hip abduction
VARIATIONS OF ACTIVE EXERCISE

VARIATIONS OF ACTIVE EXERCISE
§ Exercise in position corresponding to 5th or
6th month
§ BUT NEVER are posterior pelvic tilt, lumbar
spine flexion, or shoulder protraction present
ACTIVATION OF DNF ACTIVATION OF DNF
§ Uprighting of C-spine
§ T4 stabilization
§ SCM, Scalenes
relaxed
§ Activation of DNF
towards T4
§ By pushing C spine
against the fingers Scapulae in abduction and
§ By C-spine flexion support
T4 punctum fixum for DNF
DNF= deep neck flexors www.rehabps.com www.rehabps.com

EXERCISES IN SITTING POSITION

EXERCISES IN SITTING POSITION –
(8-9 MONTH OF DEVELOPMENT) ACTIVATION OF ABDOMINALS
§ Lean trunk back about
20 degrees
§ Spine straight
§ Pelvis and chest in
neutral position
§ Symmetrical
distribution of IAP
§ C spine in line with the
rest of spine
§ Activation of DNF
EXERCISES IN SITTING POSITION - EXERCISES IN SITTING

CHEST POSITION + ACTIVITY OF DNF POSITION - SHOULDER
§ Manual contact on the BLADE POSITION
sternum and T spine
“sandwich” § Sitting, spine uprighted
§ Chest is taken into caudal § Manual contact on the
position scapula and anterior
§ Approximation toward neutral part of shoulder girdle
pelvis facilitates uprighting of “sandwich“
spine
§ Reach neutral position
§ Assisted inclination backward of shoulder blade (ABD
activates DNF more (if head and caudal)
in line with spine)
EXERCISES IN SITTING POSITION - TOOLS
PRONE

3MM PRONE DIAPHRAGM BREATHING 3MM PRONE

Initial position corresponds to the position of DIAPHRAGM BREATHING
assessment
§ Therapists fingers on lateral side of the abdominal wall § Therapists fingers are on lumbar spine (proc.
spinosi)
Instruction
§ Client follows this facilitation as far as the lumbar
§ Inhale down in to belly against the therapist’s fingers, spine is uprighted into neutral position
keep that pressure during exhalation
§ Fotky obou způsobů
3MM PRONE: PELVIC GUIDING

Initial position corresponds to the position of
3MM PRONE
assessment SHOULDERS PLACING
§ Manual contact on
Initial position
§ Sacrum
corresponds to the
§ ASIS
position of assessment
§ Therapist guides pelvis into neutral position
§ Patient's goal is to maintain position when manual § Manual guiding of the
contact is removed scapulae into caudal
neutral position
§ Manual approximation of
the scapulae to the chest
and to support (medial
epicondyles of elbows)
3MM PRONE 3MM PRONE

HEAD GUIDING (PLACING) HEAD GUIDING
(PLACING)
assessment § Manual
approximation
§ Manual guiding of the head into neutral from top of the
position(chin tuck) head (vertex) into
T4
§ Manual contact
on top of head
for spine
elongation

3MM PRONE T-SPINE CORRECTION 3MM PRONE MODIFICATIONS

assessment § Support both elbows and
§ Manual contact on the top of kyphosis guiding T symphysis
spine in uprighting (for kyphotic spine) § Sagittal stabilization
§ Then phasic movement follows
§ Head elevation
§ Head rotation
§ Lower extremity extension
§ Manual contact from below T lordosis guiding T spine

to upright
LOW QUADRUPED LOW QUADRUPED TRANSITION

§ Beneficial for people
with excessive L
lordosis or T
kyphosis
Initial position
§ Kneeling, shins support, mild external rotation , ABD in
hips, feet out of table § Movement forward
§ Ischial tuberosities above the heels § Spine stays axially extended, elongated,
§ Elbow support on medial epicondyles movement are provided mainly in hips and
§ Pelvis neutral glenohumeral joints
LOW QUADRUPED RESISTED MOVEMENT QUADRUPED

§ Phasic movement of stepping forward arm
with/without resistance § Approximation in to
the glenoid cavity to
§ All segments are integrated (supporting, moving) improve centration of
§ Resistance of ABD, ER, FLX, supination or the shoulder blade
specifically only one component of motion
§ Approximation in to the palm to improve

hand support

QUADRUPED QUADRUPED
§ Axial trunk rotation against resistance without
§ Approximation in to the hip to improve pelvic distortion
support on shins and activate IAP
MODIFICATIONS OF QUADRUPED POSITION MODIFICATIONS OF QUADRUPED POSITION

§ Palms or knees on unstable
surface
• Exercise on the big gym-ball
§ Pelvis (or thighs on unstable

surface) • Slow movement of the legs:
flexion-extension
§ Rythmic stabilization
SUMMARY
Cooperation of patient is needed:

§ Motivation of patient
§ Variations of position, number of repetitions, volume of
loading is strictly individual and can vary in one patient
§ Home exercise on daily basis
§ Opportunity of self correction or be checked
§ Short exercises which can be provided in ADL (working
position,…)
§ 3-5 times a day for 6-8 weeks with focus

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www.rehabps.com 06.12.

1. Soft tissue techniques

ACHIEVE NEUTRAL POSITION OF THE CHEST

Manual contact Thera-Band

IAP DISTRIBUTION WITH CORRECT IAP DISTRIBUTION WITH CORRECT

Dynamic Neuromuscular Stabilization 1

PRINCIPLES OF DNS TREATMENT PRINCIPLES OF DNS TREATMENT

EXERCISE AGAINST RESISTANCE EXERCISE AGAINST RESISTANCE

PRINCIPLES OF DNS TREATMENT 1.TO IMPROVE THE SAGITTAL STABILIZATION

Dynamic Neuromuscular Stabilization 2

2. TO IMPROVE THE JOINT CENTRATION 3.DIFFERENTIATION OF FUNCTIONS IN

§ in closed or open kinetic chain

THERAPY AND ACTIVE EXERCISE ACTIVE EXERCISE TO ACHIEVE

Dynamic Neuromuscular Stabilization 3

ACTIVE EXERCISE TO ACHIEVE SAGITTAL

VARIATIONS OF ACTIVE EXERCISES ARM FLEX/EXT – OPEN KINETIC CHAIN (OKC)

Dynamic Neuromuscular Stabilization 4

VARIATIONS OF ACTIVE EXERCISES VARIATIONS OF ACTIVE EXERCISES

VARIATIONS OF ACTIVE EXERCISE

ACTIVATION OF DNF ACTIVATION OF DNF

DNF= deep neck flexors www.rehabps.com www.rehabps.com

Dynamic Neuromuscular Stabilization 5

EXERCISES IN SITTING POSITION

EXERCISES IN SITTING POSITION - EXERCISES IN SITTING

EXERCISES IN SITTING POSITION - TOOLS

Dynamic Neuromuscular Stabilization 6

3MM PRONE DIAPHRAGM BREATHING 3MM PRONE

§ Fotky obou způsobů

3MM PRONE: PELVIC GUIDING

3MM PRONE 3MM PRONE

Dynamic Neuromuscular Stabilization 7

3MM PRONE T-SPINE CORRECTION 3MM PRONE MODIFICATIONS

§ Manual contact from below T lordosis guiding T spine

LOW QUADRUPED LOW QUADRUPED TRANSITION

LOW QUADRUPED RESISTED MOVEMENT QUADRUPED

§ Approximation in to the palm to improve

Dynamic Neuromuscular Stabilization 8

MODIFICATIONS OF QUADRUPED POSITION MODIFICATIONS OF QUADRUPED POSITION

§ Pelvis (or thighs on unstable

Cooperation of patient is needed:

Dynamic Neuromuscular Stabilization 9

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