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

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I guess this week is Michael Runtala. Michael's a chiropractor based out of San Diego, California, where he has a practice that focuses on rehabilitation, which is how I met him. In addition to his practice treating patients and training a wide variety of patients, he's also one of only 18 international instructors for the Prague School of Rehabilitation teaching Dynamic Neuromuscular Stabilization, also known as DNS. He serves as part of the PGA Tour Sports Medicine Team and the USA Surfing Performance Committee. This is an episode that's really dedicated to understanding the Prague School of Rehabilitation and DNS, or Dynamic Neuromuscular Stabilization, which many of you have probably heard me talk about in the past. It came up a little bit during the podcast with Beth Lewis, and it's come up on a few other podcasts. It also comes up from time to time in social media when I post videos of some of the movements that we do in our DNS training. In this episode we get into the history of DNS, which is a relatively new discipline. It's really been around less than 20 years, and how it grew out of the Prague School of Rehabilitation, who the effectively the founding fathers of that school of thinking were, dating back to the 1950s. We then kind of get into how the developmental milestones of an infant factor into or weigh into basically things that anyone listening to this should care about, which is how they move and how they function and how they avoid injury and maintain longevity. So this is a complicated episode in the sense that I have to be honest, I think some of the concepts here don't always lend themselves well to discussion. I think being able to watch this on video gets a little bit easier because at least you can see some of the hand gestures. And of course, this episode will be accompanied by a video where Michael, Beth and I go through many of the foundational movements. Now, that video will be available only for the subscribers, but I certainly would encourage all subscribers or even non subscribers to sign up to make sure that they see that, because I think that's where a lot of the heavy lifting gets done. Ultimately, of course, DNS is something that needs to be felt more than watched. So my real hope is that most people try to put some of this into practice and begin to experience it. So without further delay, please enjoy my conversation with Michael Rintala. Hey, Michael, thanks for coming all the way out to Austin to work on some DNS for a few days with me and Beth.

Thanks for having me. Thank you.

Been wanting to sit down for quite a while and obviously the events of 2020 kind of got in the way of that. But maybe just start for folks by giving a little bit of your background. You grew up in Northern California, right?

Yeah, I grew up in Northern California and eventually went to school down in San Diego at UC San Diego.

What sports did you play growing up?

My primary sport or the sport that I was most passionate about was tennis. And interested in that from an early age, played other sports, other organized sports, but tennis was the one that I was drawn to and had the passion for so early on, specialized in that, played lots of junior tennis tournaments, trained a lot, eventually played in college. And that obsession or passion kind of drove me to the way that I practice today. I'm a chiropractor. I'm based out of San Diego, California. As you know, I specialize in rehabilitation sports medicine. I am also, so I have the private practice there. I'm fortunate enough to also be able to spend some time on the PGA Tour and the World Surf League Tour as part of their sports medicine crew or team. And also fortunate enough to be part of USA Surfing Performance Committee, helping with assessing and training the US Athletes, the surfing athletes for the upcoming Olympics. Cool.

Today, obviously, the thing we want to talk about is this super kind of deep dive into something called dynamic neuromuscular stabilization. Now, folks listening to this have probably heard me talk about this in the past. They follow me on social media. They'll notice from time to time I'm doing movements that probably look a little silly sometimes. Working with you or working with Beth or working with another colleague of ours, Michael Stromsness is actually how we all met. But I think for the purpose of this discussion, let's assume a person has never heard of DNS, has never heard of the Prague School or any of these things. Can you, in a somewhat succinct but not terribly brief manner explain to people how all of this school of rehabilitation coalesced around this idea of what we call DNS. So going back to the founding fathers of the Prague School and what these various insights were that each of them had and how that sort of came together.

DNS, or dynamic Neuromuscular Stabilization, kind of built on some pioneers of functional rehabilitation. There's many that have been part of the Prague School of Rehabilitation. But I think talking about the influence on the development of dynamic neuromuscular stabilization by Professor Pavel Kolaj, who runs the rehabilitation department at Prague School at this time. I think we need to go back post World War II, Cold War era. 1950s is where Prague School of Rehabilitation was really founded. And it was founded as part of the medical faculty of Charles University in Prague in the Czech Republic or formerly Czechoslovakia and now Czech Republic. And being post World War II, Cold War era. So they were in Eastern Europe behind the wall. That may have been a factor for their not reliance, but tendency towards the use of observation in both diagnostic diagnosis, both observation and palpation for diagnosis and treatment. All three of these pioneers were neurologists.

And who are the three?

Vladimir Janda, Karl Leavitt and Balclav Vojta. Professor Janda he had a keen sense of observation and he formulated concepts and principles that tied into postural habituation, specifically the tendency for specific musculature to tend towards tightness and other musculature to tend towards weakness. And he termed this upper cross and lower cross syndrome. So, for example, with an upper cross syndrome, meaning the neck and shoulder region with demands of life and a tendency towards postural habituation, such as with sustained seated postures, there's a tendency towards the muscles in the back of the neck, the occipital muscles, the sternocleidomastoid muscle, which is the muscle that also attaches to the skull and down to the sternoclavicular joint, the pec muscles, the upper traps, that musculature would tend towards a tightening or an over activation. Other musculature in the upper extremity, the serratus, which attaches to the ribs and the back of the scapula, the deep neck flexors, the middle and lower traps would have a tendency to tend towards a weakness and with that tendency towards over utilization or hypertonicity and underutilization inhibition weakness that would also. He also recognized that that would affect the quality of movement throughout the kinematic chain and subsequently would lead to overload in specific areas throughout that kinematic chain. So that was a big contribution on his part.

Where would those places of overload be? So if you have this tightness in the muscles you've described, the weakness in the muscles you've described, what is the consequence of that? Where does that load get distributed?

Right. So with that imbalance and that tendency towards postural habituation, you would see a tendency to overload in the transitional areas throughout the spine and throughout the extremity. So I didn't go into the specifics for lower cross syndrome. Lower cross syndrome, you have a tendency for the hip flexor complex to be overactive, tightened. So the psoas, iliopsoas, rectus femoris, the back extensor musculature will also tend towards tightness. And then the weakness or the inhibition will tend to be towards the lower abdominal region and the gluteal region. So looking at it globally, you would see a tendency to overload again throughout the extremities. So the hip joint, the knee joint, but also specifically dealing with the spine, the lumbar sacral region, thoracic lumbar region, and the cervical thoracic region, all the areas where you see the transition of the curvatures, lordosis and kyphosis. And with that tendency for overload, you will get repetitive stresses on the passive structures within that kinematic chain. So as a clinician, we know that if you tend to image these areas or if you image the spine, these are the areas that tend to have the most degenerative changes or the most disc pathology. And those changes aren't usually traumatic, they're not acute, they're accumulated over time. So the observation of these postural patterns or postural syndromes, and then the recognition of the dysfunction with movement efficiency that it caused, led him to develop specific treatments, both exercise wise and manual wise, to address those issues.

Yonda also had suffered polio as a youngster, didn't he?

Yeah, so he had suffered the residual effects, the post polio type syndrome. And that was probably a motivation for his passion for rehabilitation, his passion for the observation of movement. His colleague, Carl Levitt, also a neurologist, he shared that observation, palpation, tendency, to utilize that for diagnosis and treatment. He specifically focused on joint dysfunction, soft tissue dysfunction, as it related to those upper and lower cross syndromes. So he developed specific mobilization techniques for both the joint and the soft tissues. The addressing what they were seeing with those postural habituation and movement dysfunction. The third pioneer, also a neurologist, but also a pediatric neurologist, was Volkla Vojta. His Observations observing the ontogenesis or the development of motor function after birth during the first 12 months, where the postural foundations are established neurologically. He developed specific tests called postural reactions, where he could tell the quality or the health of the maturation of the central nervous system during that period of time. And by doing this, he could assess whether there was pathology or a healthy developing central nervous system. So he developed seven specific postural reaction tests, developed and modified some other ones, utilized primitive reflexes and just observation, observation of the infant during development to be able to recognize the biological age, meaning the maturation of that central nervous system as compared to the chronological age. So for example, if you had a six month old infant that was moving and reacting like a six week old infant, that would be an indication that there was some central nervous system pathology. His focus was on treatment of the cerebral palsy infant and patient. And he was able to utilize that observation. Those observation of the postural reactions, the assessment of the primitive reflexes to recognize early on before it would manifest clinically. So that interventions could be taken earlier on to take advantage of the neuroplasticity, the ability of the brain to form motor engrams more efficiently and work around those central lesions that you see with cerebral palsy. So all three of these founding members are founders of Prague School of Rehabilitation were Professor Collage's colleagues, mentors, instructors, they shared patients, they discussed cases. And Pawel Collage developed or evolved all that knowledge and experience into what we call dynamic neuromuscular stabilization today, before Pavel came along.

So fast forward, this started in the 50s, but fast forward to the 90s. So the Prague School is well established. You have these sort of founding fathers, so to speak. What were the applications of the Prague School at that time? How much of it was rehabilitation for kids with cerebral palsy or rehabilitation for people who were injured versus prehabilitation for athletes. Like, what was the breadth of the applicability of the Prague School?

Prague School, it's a group of clinicians and more the early 90s. The application was primarily rehabilitation, cerebral palsy, general population. With Pavel, Professor Kolaj, just to go in a little bit of his background, you know, again, he's the head of Prague School of Rehabilitation. He's also head clinician for the Czech Olympic teams and Czech national sports teams, hockey, soccer, men's and women's tennis. He himself was a high level Olympic level gymnast. So he's a pediatric physiotherapist as well. His work with those three pioneers, his experience as an athlete, his experience Treating cerebral palsy and infants. He took that or started to apply that base of knowledge to the athletic population. And the focus of and the thinking of these founders of Prague School and Prague School today is the influence of the central nervous system is huge and kind of king as far as facilitating the efficiency of transfer of load throughout that kinematic chain. So early on, the focus was more rehabilitation over multiple populations. But maybe late 90s, early 2000s, Pavel started to apply those teachings to that.

Athletic population, meaning to an uninjured athletic population or to an injured athletic population.

Probably at that time more of an injured population. Two standout athletes that he was able to work with and integrate his concepts and principles of dynamic stability were Jean Zelezny. Hopefully I say that right. He was a Olympic javelin thrower, three time gold medal winner, still holds the record for javelin, 98.48 meters, I believe. And the other one is Jamir Jagr, hockey player, Czech hockey player. He was able to help and work with them, help them rehabilitate from injuries, but then also integrate the concepts and principles of dynamic neuromuscular stabilization to one, decrease the risk of re injury. But two, also provide the potential for better performance. And we can talk about specifics of those concepts and principles.

Yeah. So we're into the early 2000s, where now Pavel's basically taking some of the fundamental principles from the Prague School and creating this new discipline. Let's use each of the words to explain to people what this is. So dynamic, of course, is movement, right. It's not just static. It applies to in motion. Neuromuscular, I think, explains the connection between the nervous system, both the central nervous system and the peripheral nervous system. But really, as you said, an emphasis on the central nervous system and how that connects to the muscular system. So a lot of people, I think, assume that acts of strength are purely muscular and they don't realize the neurologic control of those things. For me personally, the hardest one to explain to an unsuspecting audience is stabilization. Now, I have a way that I like to explain it, but I want to hear you go first.

Okay. It's important to talk about the utilization of developmental kinesiology as a way to explain posture and explain dynamic stabilization. When we're first born, functionally and structurally, we are immature. So our central nervous system is still maturing, our bones are still forming. The first weeks of life, first four to six weeks of life. The lower central nervous system structures, the brainstem levels kind of dominant. So primitive reflexes are dominant examples of.

That suck reflex Sucking reflex, reflex, grasping, obviously being able to blink. I mean the most primitive reflexes that our species, I mean, we take these for granted.

So they help keep us alive during that period of time. So as that central nervous system matures and if it's maturing in a healthy, healthy way by a three month period of time, actually, let me go back, usually starting maybe eight weeks, we start to facilitate the synergy, coordination and timing of the deep stabilizing group of musculature. And that's diaphragm, pelvic floor, the entire abdominal wall, the intersegmental spinal musculature that runs throughout the entire spine.

All right, I'm going to stop you right here. We are going to talk about these things so much that I want to make people understand them. So let's go back to the first one. Everybody's heard of their diaphragm, but let's put some actual metrics to it. It's a dome shaped muscle, it's a striated muscle, but it has kind of a non muscular part as well. But I think what most people don't appreciate is how big it is.

Right.

And how I can't even remember it's been. Back when I was in school, I had to know every attachment of it. But do you recall how far it attaches down and up on both the ribs and the vertebral bodies?

Yeah. So the diaphragm, just think of it like a big parachute or a big sheath of muscle that separates the abdominal cavity from the heart and lungs. The attachments, it has attachments on the lower six ribs on the back of the xiphoid process, which is a little bone at the end of the sternum. And then also attachments on L1, L2 vertebra, so right around the thoracic lumbar junction.

So that's just an enormous expanse of attachment, attachments being where the muscles attach and anchor. And therefore that gives you a sense of what their lever capacity is, what they can actually contract. Right.

So there's those attachments and then there's a central tendon that when the diaphragm activates, so one of the primary functions is respiration. So I go to take a breath in, that diaphragm activates, descends the central tendon, drops the lungs expand, that change in pressure, you're able to draw air into the lungs and then there's a recoil of the diaphragm and the air comes out. So there's a primary respiratory function during the first weeks of development or ontogenesis which is the study of motor development after birth, it's primary respiratory function, the central nervous system has not matured to the point to create the synergy within the other deep stabilizing group of musculature to create that fixed point through the trunk and the pelvis. So by around three months period of time, that central nervous system has matured to the point where now the hardwired genetic ingrained motor programs start to manifest themselves. So we start to see this coordinated activity of that deep group of musculature.

So we've now, I mean, for me, and I think for many people, a very helpful image is that of a cylinder. The strongest possible cylinder, right, would have a big top, a big bottom, and a beautifully symmetric side compartment to it, right? A lousy cylinder would have a tiny little bottom, a big top and a dented middle. So if the diaphragm formulates the top of that cylinder, what makes up the bottom of that cylinder?

So the bottom of the cylinder, we're looking at the pelvic floor, which is an area of musculature, basically where the babies come out. And that musculature will coordinate the regulation or management of intra abdominal pressure that is created with the descending of the diaphragm. So the diaphragm, three main functions, respiration. But there's also obviously this huge postural function where it descends even more and creates an intra abdominal pressure, so that when that pressure is created, the pelvic floor will eccentrically load, meaning musculature is active, but stretches. You can think of it like wind blowing into a sail. Where the wind blows into the sail, it opens and activates, and then it holds and maintains and the pressure. But then at the same time, we have the entire abdominal wall, which consists of the rectus muscles, our six pack muscles, our oblique musculature, which is musculature that crosses the body, comes up and has attachments onto the thoracic cage or the rib cage, and then a big one called transverse abdominis, which wraps around from the back, the thoracolumbar fascia around to the front. So as that diaphragm descends to facilitate a stabilizing function, that intra abdominal pressure is created, that musculature reacts to the pressure, there's an eccentric load and then an isometric. And then as we coordinate, so we have respiratory function, postural function, but we have to now coordinate between both respiratory and postural functions. So our central nervous system, our brain needs to manage that pressure to provide enough stability, but also allow the diaphragm to also allow the lungs to expand. This coordination is usually where we see people kind of falling apart. And if they fall apart, they'll tend towards what Yonda saw, which is that over utilization. So in the lower cross syndrome of the extensor musculature and the flexor musculature, because we lose that synergy of that deep stabilization. And if we lose that synergy and that ability to create that fixed point, then our brains do their jobs, which is to find a way to still move and do tasks that we need to do. But in doing so, we'll go to more of a high threshold or like I describe, more of a compensatory pattern. So developmentally that three month period of time is where we ideally will have that synergy, coordination and timing of that deep group of musculature that will allow the infant to create a fixed point through the trunk and the pelvis. And then also with that management of that intra abdominal pressure, there's a loading on the front of the spine. And with that loading, we get an uprighting effect throughout the spine. So then the intersegmental spinal musculature are eccentrically loading and managing that pressure against the spine to help with that uprighting effect and that unloading effect.

Let's again make sure people know exactly what we mean because we're going to use the terms a lot when you talk about eccentrically versus concentrically loading. To me, the easiest way to define it is just using the definitions, right? So a muscle is concentrically loaded when it's getting shorter as it's being loaded. Eccentrically is getting longer as it's being loaded. So for example, a bicep curl, this is the concentric phase of loading. This is the eccentric phase of loading. What a lot of people take for granted is both of those are important. But most people when training tend to emphasize the concentric and don't realize the eccentric. I heard a great story. I think it was actually from Michael Stromsness that when a group of US weightlifters visited a group of Eastern European weightlifters, I don't know, maybe it was even you that told this story. They realized that they were counting reps differently. So the American lifters would consider a Rep. 1 is up and down. So they were putting all their effort into the concentric, but then more or less dropping the weight on the way down, not really focusing on the effort to put the weight down. And the Eastern European lifters were doing the opposite. Right. They were counting it as two reps, it's up, one down. So it was just as much effort into that eccentric. And it's not to say one is right or wrong because they serve different purposes. Obviously more emphasis on the eccentric will create more hypertrophy. So there are times that you want both. But again, when you look at, for example, and we'll get to this, I'm sure, but when you look at hip abduction, the importance of being able to eccentrically control that is such an important part of injury prevention. And you can spend all the time in the world working on concentrically doing that. So later today when we actually do some stuff on the mat, you'll have some exercises to demonstrate that.

Yeah, the observation having knowledge of the developmental kinesiology or the ontogenesis and watching that maturation of the central nervous system and with that healthy maturation, seeing the synergy of the deep stabilization, providing that fixed point and then allowing efficient transfer of force and load throughout that trunk and pelvis area. What these pioneers, Vojta, Yonda, Levitt Kollaj noticed was the importance of the quality basically training that central nervous system. Because if you can facilitate that ideal stabilization stereotype and synergy, then you provide what Professor Kolaj calls centration throughout that chain of movement throughout that kinematic chain. And what he describes centration as is, for example, let's say you have the hip joint is the ability to maintain an ideal position of the femur and the acetabulum, which is the hip joint, throughout that full range of motion. In order to do that you need a synergy or a nice interplay between agonist antagonist like you described the biceps curl. So an interplay between concentric eccentric activity of the opposing musculature around the joint to help maintain that position. And if that is compromised throughout any part of that kinematic chain, it's going to affect the quality of centration or transfer of force and load above and below that region. So the quality of that synergy, coordination, timing of that deep stabilization is what Prague School is focusing on with assessment and with their treatment methods. And this is based out of that observation of developmental kinesiology, which is the neurophysiological aspects of the maturing locomotor system. They utilize that as their definition of dynamic movement, dynamic posture, ideal posture.

Let's go back to the three month old infant and start talking about what normal developmental milestones are through the lens of DNS and picking it up at three months. So what is a three month old infant starting to demonstrate and how Is that progressing as they become six months, nine months, a year, et cetera?

Right at three months with that ability to create that fixed point. Now the larger, longer musculature and larger muscle groups have something to anchor off of. So creating that fixed point, for example, allows the infant to now turn their head and fix their gaze. Prior to that, during those first weeks of life, the ability to fix their gaze is not there by three months. Providing that stable point. Now they can turn, fix their gaze. Now they start to get more of the somatosensory input from the environment, which is going to trigger an external cue or a drive to start to explore. The infant at that period of time can lift their legs out of the base of support. So they can, you'll see a triple flexion. So 90 degrees at the hip, 90 degrees at the knee, neutral position of the ankle joint or subtalar joint, they'll be able to bring their hands together and bring their hands to their, to their mouth.

And let's explain what's actually required to do that because again, most adults would take that for granted. But what is it neuromuscularly that is being hardwired in that three month old infant that is pretty impressive. And when you really stop to think about it, that they're able to bring both legs up, coordinate that movement? And by the way, are they necessarily doing that the way a 50 year old person would do that if you laid them on their back? Having now watched a lot of infants, they tend to all kind of do it in a very similar way, whereas adults tend to not do it in.

A certain way neurologically. The coordination and timing of that deep stabilization group of musculature needs to be on point to be able to create a fixed point so that again, the larger muscle groups can anchor off that to bring the legs up. Now the infant has, you know, there's a different thoracic cage size at that point. Their head in relation to their body is bigger, their limb length is bigger, they're still growing, the bones are still forming. So that's much different than a 50 year old. Our limb proportions are different, our mobility is going to be different. So we may have different body proportions, mobility, but we all went through these developmental milestones and most of us develop our central nervous system in a healthy way. So we still have those same motor patterns that our central nervous system is going to want to kick into. Some of the efficiency of accessing those nice stereotypical motor patterns that we're born with can be compromised due to soft tissue Dysfunction, rigidity, lack of range of motion throughout our joints, postural habituation that Yonda described, all that factors into our, can override the access to those ideal patterns. What Prague School tries to do is with the specific assessments, assess that efficiency of that deep stabilization system, whatever age that we're at, and then utilize specific, what we call active exercises, which are based off of the developmental milestones, which we'll get back to in a second, to utilize specific points of support and positioning to help wake up or facilitate those patterns that we still have as adults. So 3 months of age is the start of that ability to feel to create a sagittal stabilization.

Tell people what sagittal means versus coronal.

So sagittal is kind of like straight ahead. Frontal plane would be if you're on your side or to the side. And then there's transverse plane, which is, think about rotating in the transverse plane.

So what happens now as they approach.

Six months of age, three months, you see the start. Four months, that coordination is usually complete. Four, four and a half months, once they've completed that ideal facilitation of a fixed point, now they start to be able to utilize the oblique slings. And you'll start to see some differentiation in the pelvis and the limbs. And as that synergy gets more and more efficient, which means better, better management of that intra abdominal pressure, you'll see the hips coming up into higher position, the legs coming up into being able to come up into a higher position, the infant's range of reach will improve as well. At four months, they're able to touch the groin area. At five months, they can reach their knees. At six months they can reach their feet. And then by seven months, they're bringing the foot to the mouth.

And just to be clear, most people would say, is that just a result of increasing flexibility? But really the answer is not so much that they have more flexibility. They were quite flexible at birth. It's more that they now have the motor control and the stability to coordinate something that is everywhere from shoulder to foot or hand to foot, basically.

Right. And do it in an efficient manner. So I'm a parent, you're a parent, and you remember when the kids were developing, I get this all the time, they're like, oh, my son was rolling all the way over. At three months, that is possible. They can normally. Well, not normally, but ideally at that six month period of time, there's enough of that synergy and coordination and timing that the infant, you'll see the infant at that time rolling onto its Stomach. Now, they could maybe do it at three months, but they're not going to do it with that coordination and that efficiency of transfer of force and load. You may see them turn and kind of revert back to more of that. The newborn posture, meaning they're finding a way to turn. They're using more of a compensatory pattern to make that action happen. Kind of the same thing you see with movement with adults. If the synergy, coordination, timing of deep stabilization is not on point, they find a way to move. But when they move, as with the first weeks of life, the newborn infant, you'll see anterior pelvic tilt. You see a flaring of the rib cage, the shoulders, you'll see elevation, protraction, reclination, or extension through the cervical spine. The newborn, when they look or when they move, the whole body is moving. They don't have that ability to create that fixed point, but they're still able to make movements as they're going through the developmental milestones. With that motivation or that drive to move and explore their environment, they may find ways to reach that toy, but not be creating the ideal centration and stabilization with the central nervous system maturation. It's not like at three months, four months, six months, boom, they wake up and automatically they're in this perfect synergy, coordination, timing. As that central nervous system is maturing, there's thousands of trials and errors. They're forming the brain mapping and motor engrams, finding the right points of support as the coordination of the central nervous system is kicking in. So you may see at the beginning of six months, and they're turning. Maybe they're not able to keep the alignment of the diaphragms during the turning, but they're still able to do it. Maybe by then, three weeks into it now, their coordination and timing has become more efficient and better, and they're able to make that turn with a better quality of activation.

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

So what you see with the developmental milestones at three months, we talked about with the newborn, you have more of the lower central nervous system structures are maturing at three months. We see more maturation in the subcortical region of the central nervous system. And that's where we get the manifestation of these postural foundations. So as that central nervous system matures, certain milestones, three months, four months, five, six, seven, you'll see the infant starting to be able to attain higher, more unstable positions. These developmental milestones are moving towards basically the verticalization process, going from either supine on the back or prone and then working their way up, trial and error learning with that healthy central nervous system maturation, where at seven months they're able to come to their side. Eight months, they come up into what we call a high oblique sit position. 9 months, they're able to crawl. 10, 11 months, you'll see them being able to attain like a kneeling position. 12 months they're squatting. 13, 14 months they're standing and then 14, 16 months on average you see the start of ambulation. Now, this is variable. Some kids, my son was walking at 10 months, others maybe 15 months, 16 months. So there's variability within these milestones of where we see the infants. But on average, these specific points, you'll see a specific competency instability and reaching or moving towards that verticalization process.

Now, if you exclude cases of pathology like CP and things like that, where there are injuries that are preventing the neuromuscular development and, and the achievement of these milestones, is it more or less the case that all kids who are given the fair chance to sort of explore and go about these things naturally will reach a certain age, call it two or three, and they'll be quite healthy from a dynamic and movement standpoint. For example, yesterday we spent a bunch of time looking at my three and a half year old and frankly, it's a clinic in movement at that age. Right. Is it safe to assume basically all 3 year olds move really, really well? They haven't started to get into the habituated movement patterns that will begin to destroy them. Right? Yeah.

Vojta and others talk about, usually what they see is around 70% of infants are going to have that healthy central nervous system maturation, go through the first weeks of life, the postural foundations, the three to 12 months, the subcortical. And then from two, four to six years of age you have more of the cortical maturation where you see fine motor dexterity and movement, ability to write and, and you see the language develop and you see motor learning, sorry, the.

Subcortical phase goes till about 2, 3.

To 12 months is where we see these postural foundations. After that you start to get that cortical integration maturation. But the motor learning and the process.

Yeah, they obviously overlap.

It's like 2 to 6, but I mean, and beyond.

Now, I'm surprised to hear you say only 70%.

Right. I don't know if I can't say the study, maybe it's their observation. So they talk about 70% normal maturation, the other 30%, it's a spectrum. So you'll have on one end the CP child or the CNS pathology, but then there's this spectrum on the other end of the spectrum. Yonda called it minimal brain dysfunction. It's also called central coordination disorder. So there's maybe not that ideal development, but again, there's a spectrum to that. So that may manifest during that. When we see the cortical time of central nervous system maturation, maybe there is learning disabilities or not as efficient movement patterns. And this is something that Prague School, as far as the curriculum, there's a whole pediatrics section with their curriculum, which they go deeper into that aspect of observation and specific utilization of treatment options. Usually with a healthy central nervous system maturation and a good environment for the child to explore movement and the variability of movement and do the trial and error and find their ideal points of support, you're going to see this nice, healthy maturation. Things that may compromise that. I mean, we see in modern society and culture a kid who's in their car seat six hours a day or maybe doesn't have that environment where they can explore.

I think another one that I remember Michael sharing with me was when kids are sped up on milestones. So, for example, those seats that prematurely prop kids into a seated position. Well, even before that, you know that little bobby chair where. And again, we're all guilty of this. We stuck our. I know we stuck our kids in these things, at least the first two, because when our third kid came along, I was already interested in DNS. So then he became sort of the observation for DNS. But with our first two, yeah, you're going to stick them in those silly seated chairs and they don't have the support before they're ready. So they can't even support their own weight. So they're in this slouch position. And then you put them in those things. We called it the circle of neglect. So it's like the thing where they're standing before they should be standing. So all of these things actually interfere with the normal neuromuscular development. Putting kids in shoes too early probably does a tremendous disservice to them.

Right. So ideally, they're going to have an environment where they're going to figure this out themselves versus another one is the little walkers that they'll hold on to and walk. Ideally, they're going to play with their environment and with that combination of healthy central nervous system maturation, find those ideal points of support and be able to utilize those motor patterns that are Manifested with that healthy central nervous system. So the environment that we have children in is key. And this, I mean, you can take this and look at just our society just as adults.

Let's go from, okay, so we can put them in shoes too early, put them in silly sit up seats in the circle of neglect and give them walkers. And then another huge set of insults come when they go to school, right? Because now they're sitting in chairs for six or seven hours a day. And what does that do for a six or seven year old, which is unfortunately by the time they're six, they're sort of sitting in chairs six hours a day at least. So what is that doing to interfere with this process?

This is where you start to see the start of those postural syndromes. When we get into those sustained seated postures. One of the main things that happens during those developmental milestones with healthy central nervous system maturation is we're able to keep alignment or approximation of the pelvic floor and the thoracic diaphragm. The more efficiently we do that, the more efficiently we manage intra abdominal pressure and uprighting throughout the spine and then again transfer of force and load. If we fall into repetitive postures or postural habituation, which as a society is kind of a bit prevalent, gravity is going to win. No matter how nice the chair is, we're going to start to fall into that slumping posture. And when we get into that slumping posture, the shoulders coming forward, that is actually going to create an inhibition of the diaphragm's ability to descend. And again, we need that descending of the healthy and ideal descending of the diaphragm for both respiration and stabilization. So if we start getting that descending becomes inhibited due to the postural habituation. Our brain's going to find a way to get air to the lungs so it'll start to kick in. The accessory breathing musculature, which is that the sternocleidomastoid, the upper traps muscles called the scalenes which attach to your cervical spine and the upper two ribs. You'll see the pec minor also start to help to lift the thoracic cage to help get the expansion to get the air. So again, the brain just starts to do its job, which we need air. We're going to use these guys to get the air. And it's a good short term kind of survival strategy. But if we do it often enough, that becomes the go to pattern. So you'll see a change in respiratory pattern, meaning decreased utilization of full expansion of the diaphragm and more of a pattern of over utilizing the accessory breathing musculature.

This can occur quite young. I mean, I think when we, you know, we were joking about it yesterday. But you look at my youngest, I mean, his abdomen is huge. That's obviously an enormous asset to him. You can see it when he breathes. It's abdominal expansion more than it is thoracic expansion. A child that age, if developing normally, is not using any of these accessory respiratory muscles. And there's something about this anchor point being in the abdomen, right? I mean, one of the first things I learned in DNS was how to regain intra abdominal pressure through eccentric loading of that cylinder. I don't think it had ever been presented to me how important that was, because prior to that, any amount of perceived intra abdominal pressure had been acquired through concentric loading. So, for example, when trying to pick up something heavy, you can take two strategies to that. I think most people would agree if you wanted to pick up £300 right now, you must generate pressure in the abdomen. I don't think anybody would assume that you could pick up 300 pounds, which is twice your body weight, without generating pressure here. But how you do it matters. So explain those differences. And again, either with or without the developmental lens. But I think that the developmental lens is always a great way to think about how kids move.

Right? So if you think about developmentally and how that stabilizing stereotype evolves, Think of it as an inside out strategy. You're creating an intra abdominal pressure to load the abdominal wall, and then with the loading of the abdominal wall, eccentric, isometric, and then there's this interplay of all that activity, concentric, eccentric, isometric, to manage that pressure for whatever task that you need to do. So if I'm sitting here and I'm going to pick up that pen, I need some function of stabilization to then move this limb, Provide a fixed point for my anterior posterior slings to provide a nice position for the shoulder girdle to then again get that synergy throughout the kinematic chain and pick up the pen. So there's a certain amount of management of that intra abdominal pressure that I need. If I go to the chairs that we're sitting in that we moved earlier, this is a lot more weight. I'm going to need a lot more coordination and management and creation of intra abdominal pressure to create the fixed point, to transfer the ground reactive forces through my lower extremities, through my trunk and pelvis to my arms holding the chair. So there's more facilitation of that intra abdominal pressure. So that's what we see developmentally, that quality of stabilization. And that stabilization, it's not static, it's dynamic. We should be able to manage that intra abdominal pressure through full extension, full rotation, full flexion. That's the beauty of that dynamic neuromuscular stability. And that's what we see with our, that quality we see in the high, high level athletes. We can also create stability by bracing. And if you think about bracing, if someone's going to punch me in the stomach, I may go for a concentric. And where the abdominal wall shortens and tightens, I'm still creating a stabilizing function and I can still use that to move objects or prepare for impact. When it comes to dynamic movement, the inside out strategy in the central nervous system management of that stabilization allows me to create the stability efficiently where I need it, but then also be able to, for example, relax my extremity. So with high level movers, athletes, you see, they'll have nice postural foundations. They also have very nice cortical function or body awareness. So the fetters, the Kelly Slaters and surfing, they have that ability to. Their movement looks fluid and effortless. So they have that ability to relax and efficiently stabilize where they need to stabilize. Sometimes you need to incorporate that bracing strategy on top of the facilitation of intra abdominal pressure for excessive loads. Where we go beyond our threshold, our functional threshold, meaning our ability to keep that quality of stabilization. When we go beyond that ability, we go into what we call the functional gap. And when we go into the functional gap, that's where we see more of that high threshold strategy, maybe bracing strategy to get the job done, to get that weight up, to maybe kick that ball a little extra harder training wise. And in athletics that's where those athletes spend a lot of time because they're always, they're kind of pushing that threshold all the time. So you'll see with athletes a tendency, if they're spending all their time training, competing in that functional gap beyond the, the ability to maintain the more efficient transfer of force and load, then that pattern, that high threshold compensatory pattern starts to become the norm with everything picking up the pencil. So one of the things that we try to do, or I try to do as far as with training and rehabilitation, not just with the athletes but with the general population, is help them facilitate that quality of stabilization so they can increase that threshold of being able to stay within that functional threshold or that functional capacity. So that when they do have to go into the functional gap and go to those compensatory patterns, it's not all the time.

Let's talk about an elite athlete. And again, I think the thing with the really the most elite is they don't have to train in DNS. A lot of them are just doing this naturally. I mean that's sort of what makes Roger Federer great. And one of the hallmarks of that greatness is injury prevention. It's not just the greatness at what they do, it's the longevity with which they can do it.

Yes. So when I lecture, I use Federer as an example. You look at his career, just longevity and injury wise when he has been injured. But usually you see a quick recovery. Going back to Jagr and Zhelezny. Zhelezhny had a 20 year career in javelin, which I don't think is very common. Jagr is 48. He's still playing with Jagr and Zhelezny Pavel, working with them. The emphasis was on the awareness, the facilitation of this ideal stabilizing pattern, the timing of movement, the centration throughout the kinematic chain and then with that the ability to we call, differentiate within for example the pelvis over that, that femoral head. So the focus was with them was the quality over quantity. I guess you can say what percentage.

Of his time do you think? Because obviously Federer has just an unbelievable functional capacity. How often do you think he is in excess of that in that gap zone where he is using compensatory movements that are putting long term stability at risk.

So I think when you see those athletes that rise to the top, you watch Federer, for example, you see creating the point of support, the positioning, the alignment of everything he's creating naturally that centration and that transfer of focus, force and load. There is times maybe he gets out of position or a little extra hard where he's going to go into that functional gap. He's naturally has a functional, huge functional capacity where he can maintain that. I think with him you also, and this goes to training, he has a good team. He has trainers that are programming certain things in a way and giving him certain things so that he can still facilitate that quality of movement and build strength capacity on top of that. One thing that I see, for example out on the PGA Tour, I'll see players that have good programs, good coaching. They'll tend to stay within that functional capacity. They're still pushing it and still, you know, with them it's just repetitive motion which postural Habituation, repetitive motion injury are things that compromise that synergy and coordination of that dynamic stability. So if you have good programming, dosing, loading, timing, recovery, and on top of that you have amazing body awareness and cortical function, you're going to see longevity and you're going to see nice quality of movement. What I see on the other end is players, athletes, poor training programs over training, spending too much time in the functional gap, falling into what my colleague Rich Ulm talks about, the extensor compression syndrome, which you see a lot with lifting with the power athletes, which he works with a lot of. Then you see when you have that reliance on that higher threshold, you see more incidents of injury, longer recovery versus the opposite. The Federers, yeah, they get injured, but they recover fairly quickly. And that's what you see again, Jagr and Gilesny are nice examples of that. Both Czechs and Pawel, working with them over this 20 year period of time, integrating and putting in his ideas and his experience with everything that we talked about with those rehabilitation pioneers into these athletes. Kind of like a test subject, so to speak. So now Prague School and DNS practitioners, that's what we're trying to help integrate with our athletes, with the general population.

What percentage of people that you work with are coming with an injury and therefore in need of rehabilitation, where you're now applying DNS to presumably go back to, hey, this is where the breakdown was, let's go back to where that breakdown would have occurred developmentally and go back and rebuild those steps. So you're going to learn how to stabilize your neck or stabilize your head using the stabilizing muscles appropriately. You're going to learn how to generate concentric intra abdominal pressure, and you're going to learn how to centrate ipsilaterally and contralaterally and all of these things. And then what percentage of your patients are not coming with an injury, but are coming for performance enhancement and saying, I just can't throw this fastball any faster than 89 miles per hour and the only way I'm going to get that faster is if I can create a better whip between my right hand and my left leg and hip. So those are two ends of the spectrum. And how do you spend your time on those?

Majority of people are coming to me because pain and injury, what happens, especially with the athletes, once we address that, once we calm down, whether it's, if it's an acute or chronic injury, we decrease pain and utilize the. There's different manual methods within DNS and then integrating the exercises that are based off of those developmental milestones. Once they get to a certain point, ideally I'm going to work with a trainer or with the coach and hopefully they're on the same mindset so that they can then progress to the strength training, to the specific technique. More and more these athletes are, you know, it's a combination of once they're out of pain, we work with the quality of stabilization and movement and transfer of force and load.

Let's take a group of, let's say 100 athletes who come to you in pain. Again, just looking for rough numbers. What percentage of them will buy into the thesis of this very non traditional way of rehabilitating is going to help? What percentage of that hundred will stay with the program to get better?

Not enough.

So what's the number?

10, 20%? Maybe that's it. Yeah. What I see happening, for example, Major League Baseball is integrating DNS more and more. So in San Diego with the Padres, I started to consult with them a bit. There's a hitting coach for the Dodgers that comes in and we kind of workshop ideas where he's integrating the DNS concepts and principles. So it's starting to get recognized more for that value. As far as the performance enhancement aspects of it, culturally within sport, what I see, especially in the west, they want numbers, they want what's their lift, what's their strength capacity, which is important, but I think it's also important to again integrate those two, the quality of movement and stability and then increasing their strength thresholds.

But even just with an injury. So if you, let's just say 100 athletes that are, let's say gymnasts and hockey players and football players that come in with lower back pain, you're saying only 20 of those would stick with the program until they got better. 80 of them would abandon the program before they improved.

A lot of times and just across the patient population, a lot of times, once people are out of pain, it's kind of out of sight, out of mind. They go back, they go back into their patterns.

That's what I'm trying to differentiate, which is how many of them just stick with it long enough to get out of pain. The next question I'm going to ask is once out of pain, how many of them stick with the program and switch basically from rehab to prehab?

Going back to that, one of my goals, especially with the athlete, once they're out of pain, we develop a pre habilitation kind of program and we utilize those. Again, going back to the knowledge of developmental kinesiology and developmental milestones, which later we'll actually go through. So based on what I'm seeing with their insufficiencies and with their the insufficiency of that coordination of stabilization, I will give them certain things, certain sequences of movements and exercises that they practice with awareness to facilitate better strategy for stability. And then that's part of their movement preparation. Our prehabilitation before, whether it's their strength training or their technique training or going out and performing, that's a larger percentage because that's part of what I kind of program into the rehabilitation. So some athletes will get that and they're okay, great, this is good, I'm going to go do it. And then occasionally they're coming back and getting, maybe we're adding to it based on how they're functioning now. Other athletes, they want more. And that's that smaller percentage part of it too, probably access, you know, and availability as far as being able to be in San Diego and working one on one with me. So there's different factors that will tie into how much they're they're doing, but within the whole treatment protocol or rehabilitation protocol, I'm giving them things that they should then integrate into their programs.

What is the most common chief complaint of a person that walks into your office? Is it lower back pain? That would be my guess, yeah.

Majority is low back.

Okay, so what are the most common causes of lower back pain that you.

See across the board? If they're suffering from low back pain, whether it's acute or chronic, usually there's an underlying pattern of that lack of or the inefficient activation of the deep stabilizing system and more of a tendency towards that extension compression activation that over activation of flexor extensor.

Explain what that means in a bit more detail. Given the ubiquity of this injury and the probability that 80% of the people listening to this have already experienced back pain or will experience back pain in their lives. I want to make sure if people take nothing away from this podcast, they understand the etiology of lower back pain.

Unless you've had a, let's say a car accident or a fall, that's like an acute injury that can be a cause of low back pain. The majority that I see, it's more of a chronic overload over time, that if we have that strategy of too much flexor extensor activity which compromises the positioning of the intersegmental the joints and the transfer of force and load, then with the compensatory pattern we'll see more of a hinging in through that lumbar sacral region. And with that hinging over time, it's like if you keep bending a spoon, it's going to break. You weaken the structure.

But yeah, let's talk about the actual anatomy. And yesterday I said I wished I'd brought a skeleton. So the sacrum is basically a single bone. It's actually fused. So at one point it was multiple bones.

Sacrum at the ilium.

Right. So you have this sort of one fused sacrum, and then you have these five lumbar discs numbered one through five. Now, between each of those lumbar vertebral bodies is a disc, and then there's one between the fifth lumbar vertebral body and the sacrum. So we refer to them as, you know, L3. L4 is the disc between 3 and 4, and L5 S1 is the disc between there behind each of these vertebral bodies. So these vertebral bodies are sort of held in place by the discs, but then also by the facet joints that run behind them. And it's really difficult to show this. We'll probably have to pull up some images to make this easier for people to see. But the facet joints and then sort of the lamina, which are these sort of longer bones, hold it all together, but they don't really provide this support. I think the support is probably at the facet joints and at the disc interface. Is that probably fair?

Yeah. And then think of all the musculature as the scaffolding and the levers and that help with that stabilization. And then the. The activation of that deep stabilization has an uprighting effect.

And let's talk about which muscles are on the front of that. So if you were to cut me open here, and let's just say you pull everything out of the way, so you pull my bowel out of the way, you pull everything, and you go right down onto my spine. What are the muscles you're going to see that are attached to the anterior or front portion of my vertebral bodies?

Two main ones that we can talk about is the psoas, which attaches to those transverse processes of the lumbar spine. And then the quadratus lumborum, which also attaches to those processes. Both of those, with those attachments, they also come up and they attach right where the diaphragm attaches, the crura of the diaphragm. So, you know, if you. Again, maybe you can pull up Those images and put it on the show notes. So you see all those kind of coalescing in that thoracic lumbar region. If I have that ideal activation of that descending of the diaphragm and the facilitation of that intra abdominal pressure, that pressure again loads the abdominal wall and creates that fixed point that the psoas and the quadratus are anchoring off of. If that's compromised, they don't have anything to anchor off of. And then you see that excessive extension and that overload of those facet joints.

Exaggerate what the extension posture looks like so people can see it.

So your hips will move forward.

If you picture your pelvis as a.

Bowl, your tipping the bowl forward, tipping the bowl forward. And then if you think of your rib cage, rib cage is coming forward as well.

So your spine, which normally has a bend in it, gets more of a bend.

Excessive. Yeah. And with that oblique position of the diaphragm and the pelvic floor, now there's a mechanical disadvantage of the abdominal wall.

So we took a cylinder that's supposed to sit like this and we made it like that.

So now the tendency is going to be the extensor over activity and the flexor, the psoas. So now you're just getting this repetitive compression on those facet joints, and the disc is getting this repetitive hinging flexion. And then in the center of the disc, we have the fluid or the nucleus working its way through those annular fibers as they weaken. And then that's where you get the disc. Protrusions or substance can leak out and the body will go into that spas, that protective spasm. You'll see the disc injury, but then you also see, over time, facet hypertrophy. So the degenerative changes and the accumulation of bony material trying to help stabilize. So part of my story and kind of discovering what drove me into utilizing DNS, discovering Prague school, I developed what was called a spondylolysis, which is a stress fracture in the spine part of the pars, which is kind of that arch that attaches the vertebra and then to the facet joints. So for me, with over training, poor recovery, poor postural foundations, I was premature. And looking back, knowing what I know now, looking at pictures or videos of myself, I could see that compensatory pattern. It didn't catch up to me till college. Especially as we're younger, we have a huge ability to compensate and we can get away with stuff. But in college, it caught up to me. With that stress fracture. So I was kind of like the poster boy of upper and lower cross syndrome and lack of efficient stabilizing strategy. I had plenty of motivation and drive and practice, you know, hour upon hour. But at a certain point, structure, overload of in that for me, L4, L5 region, that gave way. And when that gave way, then I went into this whole chronic pain cycle. And it wasn't until I went orthopedists, physical therapists, chiropractic, all of them helped in their own way. But it was. I knew there was something missing. So probably for selfish reasons, I went into this profession trying to figure out my own pain and try to figure out how to recover. And in medical school and same chiropractic school, first year, you're just getting bombarded with all anatomy, physiology, functional biomechanics. All of it was amazing and interesting. But I'm like, this isn't helping me. It wasn't until the second year where I was introduced to Prague School, Yonda and Levitt and what they were teaching. It was like, oh, finally something made sense. And just intuitively it made sense to what I was dealing with. So I started to learn more and more about that while I was in school, incorporating some of the treatment methods and the exercises. And that got me further along of kind of pulling myself out of my own kind of chronic pain. And then once I was out of school, 97, 98, after a few years, there was a clinician, Dr. Liebensohn, taking small groups over to Prague to learn from those pioneers and those Prague therapists. So I was able to go over there. I believe it was like an eight day intensive kind of lectures and workshops, got to see Levitt. But unfortunately, the year before Yonda had passed away. I believe Wojta passed away, I think early 2000, 2000, 2001. But that was my first introduction to Professor Pawel collage. And that time it was his ideas, talking about developmental kinesiology and then utilizing that knowledge to develop the assessments and the treatment strategies, not only to the cerebral palsy population, but then he's talking about the adults and then the sports population. So once I saw that again, that was like another light bulb and another piece of that puzzle for me to work my way out of it, out of my own situation. And then from 2003, basically I've watched this evolution of DNS, the concepts and principles turn into the actual name and then the curriculum of where we're at now.

You're quite senior within the sort of international community of DNS you're one of only 18 international instructors, isn't that about right?

Yeah, yeah.

What are the different levels of certification within DNS? The highest level being where you're at. Can anybody attain that level? Or do you have to be a chiropractor, a physician or an osteopathic physician?

So there's three tracks of the Dynamic Neuromuscular Stabilization curriculum. One is a clinical track, it's DNS A, B and C. And then the fourth course is a D course which you actually go to Prague and it's like an intensive with the Prague therapist. There's a specific exercise, sport, sequence of courses. There's three courses there. The first one is focused in clinicians only type of thing. The second one is designed for trainers as well as clinicians because ideally we design that one because we want the two populations working together and on the same page, but it's a little more focused towards less manual and more of what, how you can integrate it into a training program. The third is pediatrics, where you're going to utilize the DNS handling skills with infants. And that's a series of, I believe, three courses, with the fourth culminating in Prague. So that curriculum, I believe, started to come about 2009. And then off of that we have specialty courses where we integrate different things. One of Prague School's goals, it's, you know, they don't want DNS to be. This is a DNS technique. These are concepts and principles that professor collage building on those founders and his experience and his ideas. It's meant to be integrated into everything else. Because that's one thing I love about it, is you can easily integrate it into the good work that you're already doing, whether you're a trainer, whether you're a clinician and you do a specific technique. For example, the Prague School therapists, they do visceral mobilization. They have specific soft tissue immobilization techniques and they're constantly exploring and trying to evolve the teaching and the integration. So it's a nice knowledge base and skill set to have. Again, to enhance what you're already doing.

This afternoon we're going to go down and actually demonstrate a lot of this stuff by video because I think that it's really challenging to talk about this stuff. It's just not that amenable to a discussion. It really has to be shown and frankly, even showing it is challenging. I think experiencing it is the gold standard.

That's the ultimate. It's not just movements, it's not just specific exercises, but it's facilitating the awareness of the ideal stabilization and the support. And then with my patients or whether it's training, I want my patients or my athletes to feel that synergy and feel that ability to stabilize where they need to, but then also relax where they need to. There's a little bit of a process. It's not a cookie cutter thing like just do this, this, this. You have to put some work into it. You have to practice it both as a patient and as a clinician or trainer. And I guess that would be, you know, maybe one of the drawbacks for people is everything out there. People are doing, doing good work and trying to help people. And if they have something that's working for them and we introduce these concepts and principles and they're not easily integrated, then maybe they don't adapt them or they'll adapt a portion of them, which is fine as well. But it's something that in the curriculum we try to emphasize the need for feeling and practicing the, the movements that we can show later.

I mean, I can only speak for myself, but I wonder if my generalization is correct. I think my guess would be that the people who come to DNS late in life with an injury get better, but then stick with it are probably people who like to really tinker with things and like to toil away and don't necessarily need quick results, but can sort of anchor to a philosophy. They sort of have faith in it and then they can sort of keep pursuing it because a, it feels a lot of the time like you're not doing much. And I think for someone who's used to being quite impatient with, I want results today. And hey, I just started CrossFit and two days later I'm doing power cleans. Like, this is awesome. If that's the dopamine surge that a person needs, they're going to, I think they're going to struggle with a system where you might spend a week daily practicing, learning how to breathe again. And you'll never stop practicing that, by the way. You'll never stop practicing a really great breathing pattern and a really great pattern of accessing these deep stabilizing muscles we've spoken about and practicing all of these infant like movements. And yes, it gets more challenging over time and you do these flows that become quite enjoyable and can be very challenging. I mean they're. Most of these things I still can't even do actually, especially with weight. But I don't know, I guess I would say I always think of things in medicine through the lens of efficacy and effectiveness. So efficacy is how well does something work if it's adhered to correctly? Effectiveness is if you just throw it out in the real world, how well does it work? To me, DNS might be the single most efficacious thing I have ever come across as far as healing injury and preventing injury. I'm not sure if it's the most effective thing, which is not a knock on it. But the point is, to your point earlier, a lot of people aren't going to do it, especially once you get them out of pain, they're not going to want to stay with it. Now, I don't know why that is, but that's the thing that I would hope that DNS can improve upon in the next decade. It's only a decade old, but it's like, how do we take this thing that is so efficacious again? Meaning if a person actually does it, they're going to get better. It's almost impossible not to fix back pain, neck pain, shoulder pain. Like all of these injuries, they're going to get better. We want 90% of people to be able to stick to it once they start.

Part of that is with the curriculum. Whether you're a clinician or a trainer, part of the process is with the assessment. You're training your eye. Just like a good coach will recognize something not right with the runner or the tennis player or the golf swing, DNS will have the specific assessment and those specific exercises based off of development. Once you develop your eye and recognize where the insufficiencies are, you can recognize that insufficiency of stability within the swing, within the running, within the lift. So in my opinion, you can get to the point where you can utilize these concepts and principles, communicate them in a way to the deadlift or to the runner, where you can help them in that manner. Maybe they're not doing the specific developmental movement, but you're giving them ideas as far as loading, cueing that will facilitate that efficiency.

And that's the challenge you're dealing with in Major League Baseball is you know that there's a way to get an extra four miles an hour out of a pitch. But you also know that that athlete probably doesn't want to or doesn't have the time to. Maybe I would argue they should have the time to, but maybe doesn't want to go back and do all of the fundamental movements and master what an infant does. So now your challenge is while you're on the pitching mound, how do I put a principle in you that's going to create a little more whip like stability.

Right. Part of that is training up the staff that will be dealing with that athlete full, full time. The more skilled and movement towards mastery of that, the better it's going to be for the people that they work with. So part of that is that process, that education, that learning process. That's what I see people starting to ask for to help with because a lot of people will take the coursework and they're like, oh man, yeah, that's awesome. How do I integrate it? And that's also part of the curriculum. We've created specialty courses. So for example, there's certain expertise within Prague School. We have a Prague therapist that focuses on the running athlete. We have one of the instructors danced professionally. So we have a dance specific exercise sport course. We've done golf, we've done baseball. Dr. Ulm has a strength specific lifting specific course talking about that integration. So we're more trying to create that curriculum to help with that integration. Because if we just have the standard courses, more of that's going to tend to be clinical. But if we show how to actually do the integration within the specialty course, whoever's working with those athletes or an athlete themselves, that's going to be, we're going to be able to communicate it better because they understand that sport. We even done hockey specific. One of the Czech therapists works with the Czech national hockey team. So obviously huge experience and then we show the integration. So that's part of that evolution of trying to communicate these concepts and principles better, help people integrate them better so that we can again enhance what we're doing with our patients and with our athletes or with our people that want to focus on performance.

Well, Michael, this has been interesting and I think it's going to get a lot more interesting when we go and roll around on the mats a little bit and I think give a little bit more of a visual explanation of what a lot of this stuff looks like. So thanks so much for sharing your insights and keeping up the fight.

Thank you. That went faster than I thought and I just feel like we scratched the surface. So looking forward to showing it to help people understand it a little bit better. Thank you.

Yeah. And hopefully once people see it, they'll want to take that next step which is feeling it. And I truly think that only when you feel this do you understand it. And I think that's true of not just DNS. I think that's true of PRI and FRC and all these other things that we've spoken about that in my mind all have a place in both the world of Rehab and Prehab.

Yeah, if you can feel it, then you can start to integrate it and create that new pattern.

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Sam.