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15

Who Is the Founder of DNS?

Professor Pavel Kolar, PaedDr.
Director
Rehabilitation Clinic
2nd Medical Faculty
www.rehabps.com Charles University
Prague, Czech Republic
Kolar’s Approach to Dynamic
•! Physiotherapist by training who holds a
Neuromuscular Stabilization doctorate in pediatrics and physiology
!"#$%#&%'()%*Sport and Fitness handouts:
•! Professor of physiology
+#&"*,*
Rehabilitation Clinic
University Hospital Motol •! Head clinician for the Czech Olympic teams
Charles University – soccer, ice hockey, tennis.
Prague, Czech Republic

What is DNS? Sport

•! Sports performance
•! Concept of DNS is based on the scientific
!!Level of physical condition
principles of developmental kinesiology
-! Power/strength/speed
(DK) i.e., the neurophysiological aspects
of the maturing locomotor system. -! Endurance
!!Sport technique
•! It includes both, knowledge and a - Optimal postural foundation
theoretical base, in addition to - Movement quality/coordination
assessment, treatment, exercise and -! Movement awareness
functional strategies.

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Sport Loading Training

•! Movements with maximum muscle power •! Adequate amount of load to evoke body
adaptation
•! Increased demands on muscular
coordination •! Adequate loading time and repetition
•! Maximum range of motion •! Neuromuscular adaptation
-! Cortical control – process of motor learning (slow
•! Maximum loading on ligaments movements)
and tendons -! Motor programs – learned and fixed programs
•! Increased respiratory demands (cerebellum, basal ganglia pathways)
•! Biochemical and morphological adaptation

40".,/5+)367"8/
Training Posture
-! ./"*)0#1"23*%)4$)%*
•! Should respect anatomy and physiology of the -! 5&6)77)&8*+'22#")98*:2)0#$%)&;;;*
body (local, regional and global anatomical -! <='1=*1/$1)>"*%)4$)9*'%)#2*>/9"?&);*
parameters) -! !"#"$%*'$@/&A#B/$*%)4$)9*'%)#2*
•! Neutral joint position during the entire course of >/9"?&)*C*&'()*+,+-*%.,/0"1",+&2"#3/
movement
-! How to define neutral joint position?
-! Why is it necessary?

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Development of Postural Postural Foundation

Function
•! Postural function •! Definition of ideal posture
-! Dynamic function -! Foundation of neutral position – established
-! Precedes and follows every movement during motor development
-! Ensures position of the trunk, spine and pelvis
during movement
-! Universal pattern that stabilizes any movement – -! Neutral joint positions
controlled on subcortical level "! enables optimal loading
-! Its quality depends on quality of motor "! ideal balance between agonists and antagonists
development during early childhood "! ideal interplay with other muscles and segments
in the whole system

Neutral (Centrated) Joint

Functional Joint Centration
Positions
•! Dynamic neuromuscular strategy that leads to
optimal joint position that allows for the most
effective mechanical advantage

•! A centrated joint has the greatest interosseous

contact to allow for optimal load transference
across the joint and along the kinetic chain.

•! Allows for maximal muscle pull and protection of

passive structures
Optimal development – in any position, all the
joints are functionally centrated!

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Functional joint centration Normal (CNS) Development

= Neutral joint position
•! Enables generation fo maximum muscle
power
•! Improves sport performance

•! Ideal/balanced joint loading- decreased load Newborn 3 m/o healthy infant

on ligaments and tendons, prevents cartilage
overuse and degeneration

•! May prevent repetitive strain injury

Normal Muscle Function, Normal Posture

5 months 8 months 9 months

12 months

Program ! Function ! Structural maturation

10 months
CNS Muscle Bone (joint)

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Developmental Kinesiology Stabilization in a Sagittal Plane

Optimal pattern of core stabilization in 3 m/o infant
1st phase 0 – 4 months and in a weight lifter
sagittal stabilization matures Same muscle coordination; weight lifter just needs
more strength; joint centration same in both

What Causes Spine and Torso Trunk Stabilization

Stability? Liquid ball
phenomenon
•! Intra-abdominal pressure (IAP) is
the main stabilizer of the spine –
this pressure is applied against
the abdominal wall and the
dorsal-lumbar fascia and
supports it.
•! IAP results from ballanced co-
activity of the diaphragm and
trunk and pelvic muscles. INTRA – ABDOMINAL PRESSURE (IAP) REGULATION
Via balanced coordination between the diaphragm, pelvic
floor and abdominal muscles

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The diaphragm: 3 functions

Respiration
-! Respiration
-! Stabilization
-! Sphincter •! Breathing and stability functions are
always co-dependent.

•! Developmentally important – future

stability

**.#.3+2*%.,,(/7",.3"0/3+/37.#)1"7)6)/.90D*

Muscle Activity during Ventilation Dual Activity of Diaphragm

Muscles of Quiet Inspiration
!!Diaphragm •! Established during ontogenesis (6 months)
1.! Lowering and flattening of the dome, •! Respiratory
increased diameter of vertical thorax
•! Postural
2.! Increased IAP results from
diaphragmatic descend; diaphragm -! contraction and flattening of the D prior to
expands the lower ribs laterally. any movement
3.! Once stabilized by an increased IAP, -! Cause active response of abdominal and
continuing contraction of the costal pelvic floor muscles – ventral spinal
fibers elevates the middle and lower stabilization
ribs (Neumann, 2002).

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Ideal Respiratory Pattern Rib Movement during Respiration

!!Initial position – relationship

between chest and spine
!!Upper ribs – rotation in CV
joint - chest expansion in
ventral direction
!!Lower ribs – rotation in CV
joint causes expansion in
lateral direction
!!Sternum is stable
!!Movement occurs at SC joint –
if inadequate, AC joint
movement substitutes

Ideal Respiratory Pattern

!!Must be maintained during any dynamic
functional activities and exercises “If breathing it is not normalized –
!!Spinal stability results no other movement pattern can
!!Competition between postural and respiratory
function of the diaphragm - affects the quality of be.”
phasic movement Karel Lewit
!!For example: a tennis player w/weak stabilization
-Unable to maintain postural diaphragmatic
function while playing
!!Yoga trainers usually train abdominal breathing
(ventral protrusion only!) and forget to include the
lateral expansion

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:3.9*,*;.$+#/<6#%$+#/+</3'"/0*.&'7.-2/.#0/
Respiration and Exercises .90+2*#.,/.#0/&",1*%/26)%,")/

•! Optimal respiratory pattern is essential

for IAP regulation during exercise

•! Strength exercise – expiration while

exerting strength

•! Increased oxygen consumption

reinforces activity of auxiliary
respiratory muscles *#*$.,/ *#%+77"%3/ %+77"%3/

Stabilization Function of the

Diaphragm Open Scissors Syndrome

Optimal position of the chest is essential for

correct diaphragm function

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Ideal Abnormal
coordination coordination Development of Stabilization
Function

12m
3m 4.5 m 6 -7.5 m 8-9 m 14 -16 m

Physiological Hourglass syndrome

Developmental Kinesiology Global Motor pPatterns

•! 1st phase - 0 – 4.5 months "!Differentiation of extremities’
function
- Sagittal stabilization -! supporting function
•! 2nd phase - from 4.5 months -! stepping forward function
-! Extremity function differentiation within global
patterns "!Ipsilateral patterns - develop
•! 3rd phase - from 8 months from supine
- Development of locomotor function "!Contralateral – develop from
prone

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IPSILATERAL Global Pattern Ipsilateral Global Pattern

-! Supporting & stepping forward extremities on the
same side (turning, oblique sit)

Stepping forward -
top limbs

Support - bottom
limbs

Ipsilateral Global Pattern CONTRALATERAL Global

Patterns
- supporting & stepping forward function on
opposite sides (reaching for the toy, crawling, walking)

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Contralateral Global Pattern From contra to ipsilateral pattern

Supporting arm
Stepping forward arm

Supporting phase
changes into
stepping forward Stepping forward
phase phase changes into
supporting phase

Biomechannics of Muscle Work Biomechanics of Muscle Work

PF

"!Concentric muscle contraction – "!If proximal muscle attachment

approximation of two muscle is stabilized (punctum fixum) –
attachments the distal end moves toward
PM
proximal part (punctum mobile)
– PROXIMAL PULL =
"!The direction of muscle pull depends on STEPPING FORWARD
stabilization of the proximal or distal MOVEMENT
attachment, which is provided by other (i.e., limb’s movement in space, swing
phase, open kinematic chain)
muscles (stabilizers).

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Biomechanics of the Differentiation of Limb Function

muscle work
PM

"!Distal muscle attachment is

fixed = PF
PF
"!Proximal end moves towards
the distal (PM) – DISTAL
PULL = SUPPORTING
FUNCTION !?>>/&B$7*
(stance phase, hand or elbow !")>>'$7*@/&F#&%* *2'AE*
support, close kinematic chain) G9F'$7*>=#9)G*

Exercise Based on Developmental Kinesiology

Developmental Kinesiology Based Exercise
•! Allows training muscles during physiological
function (purposeful movements)

•! Automatically activates an ideal quality of

stabilization function 4m 4.5 m 7.5 m
•! Prevents repetitive strain injuries

•! Performance enhancement

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Exercises in Developmental Positions Conclusion

Muscles may be strong enough
in its phasic function (anatomic),
but lacking in its postural
(stabilizing) function.
9m 14 m 16 m

Conclusion DNS Tests

Core stability is not defined by

strength of abdominals or back
muscles (or any others), but results
from optimal intra-abdominal
pressure regulation

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Evaluation of Stabilization Function 1. The Diaphragm Test

a)! Do the joints and segments stay in

neutral position when loaded and during
full ROM?
b)! Which muscles are activated too much
and which are insufficient?

Postural instability – segment or a joint

looses neutral position during postural
loading or movement

The Diaphragm Test The Diaphragm Test

Correct activation
•! Palpate laterally below the lower ribs
•! Symmetrical activation
•! Slightly press against the lateral against the therapist’s
abdominal muscles fingers
•! Check the position and movement of the •! Lower chest expands in a
lower ribs lateral direction
•! Assess : Quality and •! Intercostal spaces widen
symmetry of activation •! Position of the ribs in the
transverse plane remains
the same (ribs should not
elevate!)

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The Diaphragm Test 2. The Diaphragm Test

Expiratory position of the chest
Insufficient activation
•! None or very weak activation NO !
•! Cranial movement of the ribs –
the patient is unable to
maintain the caudal, expiratory
position of the chest
•! Insufficient widening of the
lower chest and intercostal
spaces poor
stabilization of L spine
•! T spine flexion

3. Intra-Abdominal Pressure Test 3 Months Position

Training (instructions):
•!Caudal (neutral) chest position
•!Diaphragm/pelvic floor
coordination
•!Cylindrical activation of all
abdominal wall sections
Initial position •!Check for neutral neck position
•! Patient supine •!Avoid L spine arching
•! Triple flexion of the legs •!Patient must actively maintain
•! Lower legs supported neutral hip position
•! Hip abduction corresponds to the width of the •!Direct patient‘s breath as far as
shoulders, slight external rotation at the hips – the groin and dorsolateral
centrated position aspects of the abdominal wall

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Developmental Aspect Posterior Angles of the Ribs

Physiological In newborn: positioned
development 3 months: rib angles behind
Newborn anteriorly to the spine the spine
Structural and functional Normal function and normal
immaturity structural maturation
Man, unlike many
animals, is
immature at birth.
After birth, CNS
maturation occurs
Abnormal development Ideal stabilization
(stabilization) – anterior corresponds with ideal
Individual w/ placement and ”immature”
abnormal early developmental pattern
shape of the ribs remains
development

(1st year of life)

Structural
consequences:
anatomy of a
newborn

Intra-Abdominal Pressure Test Intra-Abdominal Pressure Test

Assessment Correct activation
•! The therapist brings the •! Well balanced
patient’s chest activation of all the
passively into a caudal,
expiratory position parts of the
abdominal wall
•! Then, the support is •! The chest is kept in
slowly and gradually a caudal position
removed from under •! Vertical axis of the
the patient’s legs
diaphragm
•! The patient actively •! The lower chest
holds this position widens

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Intra-Abdominal Pressure Test:

Ideal model Intra-Abdominal Pressure Test:
Poor activation
•! Activity of upper part of
Ideal activity of rectus abdominis
predominates
(co-contraction):
•! The umbilicus is pulled
in a cranial direction
•! diaphragm
•! abdominal muscles •! Inspiratory position of
•! pelvic floor muscles the chest

•! Concavity of the
abdominal wall above
the level of the groins

Intra-Abdominal Pressure Test

Poor activation
•! None or very little Diastasis
activity of the
dorsolateral parts of
the abdominal wall

•! Hyperactivity of the
paravertebral
muscles

•! Instability
(hyperextension at T/
L junction)

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4. Trunk and Neck Flexion Test

Hyperactivity of the
rectus abdominis
– upper part

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Poor Patterns
Trunk and Neck Flexion Test
"! During neck flexion, the
chest is pulled in a cranial
Correct stereotype direction
#!During neck flexion, "! The collar bones are
abdominal muscles become lifted cranially
activated "! Convexity (bulging) at
#!The collar bones do not the lateral aspects of the
elevate (no hyperactivity of abdominal wall
the pectoralis m.) Neck flexion test
#!The chest is kept in a #! Poor stereotype – the ribs
caudal position are not correctly fixed, move in
#!During trunk flexion, a lateral and cranial direction
lateral abdominal muscles
are activated

5. Intra-abdominal Pressure Test:

Sitting Position

Instruction: push against my fingers , increase intra-abdominal

pressure above your groin
Correct pattern:
The umbilicus is not pulled in and up during activation; rather, it
moves caudally
Strong symmetrical activity above the groin (pelvic floor muscles)

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Poor Patterns

•! Unable to activate lower

abdominals – poor
coordination of trunk
muscles
•! Umbilicus is pulled
inward and up during
activation (hyperactivity
of the upper section of
the rectus abdominis)
•! Frequently associated
with abdominal crease

Insufficient Segmental Movement

Middle T-spine

=>/?76#@/AB3"#)*+#/ •! Insufficiency of the deep neck

flexors: co-activation with
?")3/ extensors
•! C spine hypermobility, (head
extension)
•! Hyperactivity of auxiliary
respiratory muscles
•! Upper scapular stabilizers &
short neck extensors hyperactive
•! Insufficient lower scapular
stabilizers

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Extension Test:
insufficient pattern 7. Quadruped Rock Forward

o! The upper angles of Performance

the shoulder blades "! The patient
slightly shifts the
are pulled in a cranial head and the
direction (activity of trunk forward
the upper and middle (rock forward)
trapezius), adduction
of the upper angles Assessment
o! Abduction of the "! Hand support
lower angles "! Position of the
scapulae

Quadruped Rock Forward

Evaluate:
•! Support on palms
(tripod)
•! Scapular stability
•! Symmetry of T/L
paraspinals
•! Hypertonus of
upper stabilizers?
Wrong stereotype:
•! Hypothenar hand support (ulnar side of hand)
•! Scapular “winging” (cranial and lateral directions)
•! Hypertonus of PV T/L and upper stabilizers = elevation of
the lower leg
Kapandji, 1974

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8. The Bear Position

•! Higher & more challenging

position
•! Mistakes are more pronounced
•! Watch the position for
centration of the ankles and
the knees
•! Position of the pelvis, L spine
NO $ •! Position of the scapulae
•! Activation of the laterodorsal
parts of the abdominals
•! Neck centration, head position

YES %

9. The Squat test The Squat test

Correct pattern
•! Neutral pelvic position
•! Good activation of the laterodorsal
sections of the abdominals and
posterior diaphragm
•! Lumbar spine centration – neither
lordosis nor kyphosis
•! Centration of the hip, knee and ankle
joints
•! Correct position of the shoulder
blades - ABD & slight external
rotation
•! Shld, hip and foot should be in 1 line
•! Medial knee should line up between
2nd & 3rd toes

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The Squat test The Squat Test – Modified

Poor stereotype

•! Hyperactivity of the paraspinal •! If squat with no

muscles (T/L region) support is too
•! Anterior pelvic tilt challenging
•! Decentration of the hip, knee •! Use this modification
or ankle joint •! Modification for both,
•! Shoulder elevation, protraction assessment and
•! Head in forward drawn training
position

DNS Assessment
•! Respiration pattern – test diaphragm in different
positions, during loading, during sport
•! Evaluate and analyse sport technique or
movement
-! joint centration and torso/pelvis axes during the
movement
•! choose 2-3 DNS test - indentify insufficient or
incorrect motor patterns

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Exercise in Sport and

Sport Technique Evaluation
Fitness Based on DNS
Principles
•! Videotape athlete during
sport activity
•! Pay attention to joint
centration and movement
pattern characteristics
•! Notice any incoordination,
jerky movement, coupled
movement
•! Look for the quality of
relaxation!

DNS Exercise Principles DNS Exercise Principles

•! Correct respiration
•! Optimal sagittal stabilization •! Number of repetitions –
•! All joints and segments in neutral depends on stabilization
(centrated) positions •! Exercise only as long as
the neutral position and
•! Establish a good quality of support good quality of movement
are achieved and
maintained
•! Exercise in static positions
- improve segmental
stabilization function

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What Position and Load DNS Principles in Athletes

to Start with?
DNS based training
•! Start in posturally easier (lower)
a)! respect ideal posture as defined by
positions (developmentally
developmental kinesiology
younger)
b)! Train variability - adaptation to sport loading
•! Exercise must activate optimal
motor patterns (stabilization, c)! Cortical function training– improve sensory
support, stepping forward) integration
•! Reduce the load if abnormal
position in any segment occurs

Supine with Exercise Ball

Preparatory Exercise with Load 1)! Patient supine, legs flexed
Chest positioning IAP proper activation 2)! Push one hand and contralateral thigh
against the exercise ball
Mistakes:
•! Ball tilts laterally
•! The patient elevates shoulders
•! Increased L lordosis
•! Patient holds her breath

Assist with neutral position of Teach client how to breathe

the rib cage and costal and regulate IAP, to activate
expansion during inspiration “abdominal cylinder” prior to
any movement of the limbs

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“90-90 Supine“ with T-band Exercises in Supine

•! Supine “90-90 position”
•! Neutral = caudal position of
the ribcage during both,
exhalation and inhalation

•! Hold hands, palms facing up

The T-band is wrapped around the Maintain the basic supine position
shins (just below the knees), crossed with the head, spine, trunk and
from the front to the back side, and •! Extend your elbows as if
pelvis in a neutral position,
brought forward around the thighs (just breathe into the area above the performing a bench press
above the knees), and held in the groin. Supinate your hands while
palms (wrapped twice) with the free performing external rotation at
end of the T-band placed between the shoulders.
•! Use loads for exercise
thumb and index finger. Elbows are progression
flexed 90 degrees.

Exercises in Supine Exercise in Supine with Pulleys

Set up position: supine with legs 90-90 and sagittal
stabilization
•! Supine “90-90 position”
•! Hold weights, bend
elbows and shoulders
while maintaining
caudal position of the
chest, neutral position
of the spine and pelvis
•! Posterior delt, ER, triceps, •! Anterior delt, pecs, obligues
•! Extend elbows as in a •! Supporting arm is in 90 degree
obliques
triceps curl abduction
•! One arm - from 90°flexion
pulls into abduction against •! Stepping forward hand with
pulley resistance pulley in flexion, ER and ABD
pulls to adduction

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Exercise in Prone
Low Kneeling Exercise
•! Prone position, elbow support •! Sit on your heels
•! Increase intra-abdominal •! Knee distance = shoulder
pressure and load the distance
symphysis (without activity of the
glutes). •! Elbow support, forearms
pronated
•! Depress the shoulder blades
while keeping them apart •! Stabilize the shoulders!
•! Lift your head from mid •! Cue the client to lift his head
thoracic spine and with the C with C spine straight
spine straight. •! Guide the T spine and L
•! 3-6 reps with maximum quality spine straightening while
patient is lifting from his
heels

Quadruped Exercise Quadruped Modification

Horizontal abduction with
Basic position load

•! Centrated quadruped
position

•! Slide one knee back

and forward while
•! Centrated quadruped position •! Use pulley or weight to maintaining the pelvis
•! Spine straight! move one arm horizontal and spine
•! Knees distance = hands •! Joint centration throughout straight
distance the entire ROM
•! hips in 90°, shins and feet •! Direction of moving arm can
converge. vary

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Quadruped Modification Sitting Exercise

Arm press with optimal
Proper IAP prior to load IAP and centrated pelvis
•! Contralateral arm and leg
support
•! Supporting knee is placed
in front
•! Spine, pelvis, rib cage,
shoulders and supported
hand well centrated at all
times!
•! Stepping forward arm
moves against pulley from First, obtain well balanced IAP & Place legs on the bench in
extension with IR to FL “abdominal cylinder” during: 90-90 position
with ER a)! respiration Knee distance = shld dist.
b)! exercise Balanced IAP first and then
arm press

3M: PRONE

Developmental Positions
3 – 13 months
SUMMARY

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3M: SUPINE 4M: SUPINE

5M: PRONE 5M: SUPINE

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5M:SIDE - LYING 6M: SUPINE

6M:PRONE 7M: PRONE

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7M: 7M: SIDE SITTING - FOREARM

QUADRUPED SUPPORT

8M: SIDE SITTING - HAND 9M: CRAWLING

SUPPORT

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10M:TRIPOD 10M:
SITTING

10M:ROTATION 11M: BEAR

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11M: KNEELING
12M: SQUAT

13M: VERTICALIZATION
12M: DEEP SQUAT

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TRANSITIONS

http://www.rehabps.com/REHABILITATION/Posters.html

www.rehabps.com

DNS principles for athletic

population and training

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