Pavel Kolar and crew actually contributed to quite a few chapters in this edition, and this one here was overall very well written. Believe it or not, it even had quite a few citations!
Why they don’t cite many references in their classes is beyond me, but that’s another soapbox for another day. Onward to a rock-solid chapter.
En utero, the diaphragm’s origin begins in the cervical region, which could possibly have been an extension of the rectus abdominis muscle. As development progresses, the diaphragm caudally descends and tilts forward. When the child is between 4-6 months old, the diaphragm reaches its final position.
Throughout this period, the diaphragm initially is used for respiratory function only. As we progress through the neonatal period (28 days), we see the diaphragm progress postural and sphincter function.
The diaphragm is integral for developing requisite stability to move. Achieving movement involves co-activation of the diaphragm, abdominal, back, and pelvic muscles. This connectivity assimilates breathing, posture, and movement . If this system develops properly, we see the highest potential for motor control.
The largest developmental changes in this system occur at 3 months. Here we see the cervical and thoracic spine straighten and costal breathing initiate. 4.5 months shows extremity function differentiation, indicating a stable axial skeleton to which movement may occur.
Further progression occurs at 6 months. Here costal breathing is fully established. We also have increased diaphragm and lumbar spine stability. This part is necessary for support to occur in the quadruped position, as the proximal attachment of the psoas has a firm place to pull the baby up onto palms and thighs.
In an Ideal World
Per development, an ideal breathing pattern ought to involve the diaphragm descending in the caudal direction, with elastic recoil promoting ascension upon exhalation. As a result, the organs shift caudally as well, and the abdominal wall expands in all directions.
From a muscular perspective, we see an alternating dance of muscle activity. Inspiration requires concentric diaphragm and pelvic floor activity, which compresses the abdominal cylinder to establish intra-abdominal pressure. Ab wall expansion occurs via eccentric activity of the abdominal muscles, quadratus lumborum, spinal extensors, and hip external rotators. When we exhale, the reverse occurs: diaphragm and pelvic floor eccentrically return to their starting position and the ab wall concentrically tightens up.
Regarding the ribs, we can break them up into segments that do or do not attach to the sternum. The top 7 ribs usually attach to the sternum anteriorly, thus are influenced by sternal movement.
Physiologically normal breathing involves the sternum moving anteroposterior via sternoclavicular joint rotation. It is this movement that contributes to the pump-handle activity of the upper ribs.
The lower ribs laterally expand and open during inhalation, creating a bucket-handle movement. This motion occurs because the thoracic cavity expands anterolaterally by diaphragm and intercostal muscle activity.
But Life Isn’t All Love and Happiness
Breathing sometimes can occur pathologically. One example is paradoxical breathing. Here we see the diaphragm’s central tendon become fixed, leading the diaphragm to be eccentric upon inhalation and concentric upon exhalation. As a result, the lower ribs cranially elevate and intercostal spaces narrow. Accessory muscles begin assisting the breath, creating upper rib elevation.
Because the diaphragm does not assist postural stabilization as well, the paravertebral muscles kick into overdrive to keep us upright.
The sternum begins moving cranio-caudally, the acromioclavicular joint moves instead of the sternoclavicular joint. This change is one reason why we see shoulders elevate with accessory breathing. Hence, we can see why thoracic position is important for creating an ideal environment to breathe in.
These changes can correlate to pain states. In people with chronic low back pain, Pavel Kolar found increased flattening of the diaphragm’s lumbar portion. Another study demonstrated that decreased diaphragm activity during trunk stabilization posed a greater risk for developing low back pain.
The diaphragm can play a large influence on the viscera not only from an intra-abdominal pressure perspective but with digestion as well.
The diaphragm influences eating via the vagus nerve. In order for a bolus to reach the stomach, the diaphragm’s crural portion must relax. The reverse occurs when intragastric pressure must be attained, such as when the esophagus closes off from the stomach contents. So we can see that if diaphragm activity is not up to par, there is an increased risk of gastro-esophageal refux disease occurring.
Since the day began talking thoracic-scapula, Ron started us off by showing all the T-S connections in the body.
You will notice that the thorax is very connected to many of these areas. Therefore, it is very important to control this area early on; especially if one’s problem is in the cervical spine.
The “pattern” dictates the thorax governing the cervical spine because the neck follows suit with the rotated left thoracic spine. Thus, if we restore position to the thorax, oftentimes neck position will clear up.
From here, my man James Anderson was introduced, and we started off the
discussion with a bang.
Brain, Brain, and a Little More Brain
The first hour was spent talking about a subject much needing discussion: PRI’s cortical foundation. James really hammered the fact that our brains are what drive us to the right.
None of the previous mentioned material matters. Zones don’t matter, left AFIR, right shoulder internal rotation, nothing, if you can’t get the brain to change out of a left hemispheric dominance.
How do we do this? Per James, let’s get a zone of apposition (ZOA) in a right
Say what? All the talk you have been hearing involves getting out of this right-sided dominance. But think of PRI activity in this fashion. We are most comfortable with performing right-sided activities. So why not use graded exposure to slowly get us onto our left side? Since ZOA establishment is the foundational piece, let’s just get that and slowly work towards using our left side.
The activity above was something James showed us at Impingement and Instability. As you can see, my pelvis orients to the right and thorax to the left with this activity i.e. the pattern. However, James got one of my classmates neutral with this exercise. Because we achieved ZOA in the pattern, the brain can safely begin to lateralize to the left without a threat response sending us back into our comfortable right dominant pattern.
Explaining Superior T4
Superior T4 syndrome is another PRI concept that for me was very difficult to understand. But after AI, this syndrome was cleared up for me.
In a normal patterned individual the left ribs are externally rotated and in an inhaled state, and the right ribs are internally rotated in an exhaled state.
In a superior T4 syndrome, the first rib becomes elevated anteriorly on the right. This change occurs when the scalenes begin to act as accessory respiratory muscle.
Overactive scalenes will alter rib orientation down to T4 level because that is the level the first rib is located at.
When this elevation occurs, ribs 1-4 internally rotate on the left and externally
rotate on the right. This pulling creates torsion in this area, thus altering rib
orientation and the movement synchrony of the ribcage.
The internally rotated left upper ribs decrease apical airflow simply because there is no rib expansion. This airflow type leads to corresponding decreased shoulder internal rotation bilaterally and impaired
subclavius mobility secondary to rib and shoulder girdle compensatory positioning.
Postural Respiration on Steroids
James gave a very clear explanation as to why certain muscles are targeted in a right BC pattern. Let’s discuss them below.
Right low trap – Based on the thorax’s orientation in a patterned individual, the right low trap is long at both ends.
Kinda Too Good at: The lengthened right trap helps stabilize the right abducted thorax poorly by partnering with the right ab wall.
Goal: We want the low trap to retract and posteriorly tilt the protracted scapula, as well flex the thorax.
Left low trap – Based on the thorax’s orientation in a patterned individual, the left low trap is short on both ends.
Too good at: The left trap does very well concentrically stabilizing spinal rotation in the transverse plane secondary to shortness.
Goal: We want the left low trap to help stabilize a left abducted thorax.
Left Serratus Anterior – Shortened due to thoracic and scapular position.
Too good at: Left serratus drives the thorax into right abduction to further facilitate favorable right hemidiaphragm position.
Goal: Improve thoracic kyphosis sagitally and promote rib IR via upper fibers to drive thorax out of left rotation transversely. Will help anchor ZOA because ribs retract and increase left posterior mediastinum activity.
Right Serratus Anterior – Lost leverage by scalenes and abdominal wall shortening the surrounding areas, thus making serratus long.
Too good at: Sagittal activity.
Goal: Drives the thorax into left abduction to quiet the right ab wall and scalenes. Also externally rotate ribs to increase apical expansion.
Right Subscapularis – Mechanically disadvantaged against the lat and pecs due to scapular position.
Too good at: Not much. Trouble overpowering the lat
Goal: Will keep the lat quiet once thorax and scapula are properly positioned. If your patient/client has positive RBC tests except full shoulder internal rotation, then some issues once all these tests are clear, go after this muscle.
(In)famous Ron Quotes
• “Give the least amount necessary to be successful. Need to get you there and
then take it [the activity] away.”
• “God love ya, but I just don’t want to focus on provoking pain.”
• “If you gotta travel with pillows, you got issues.
Great James Quotes
• “The brain is right lateralized. Your 12 o’clock is not 12 o’clock.”
• “The brain is the heart of integration through the thorax.”
• “When your soul burns, you’re integrated.”
• “If you think you’re feeling your ab wall, I think you are not integrated.”
• “Don’t fight the brain.”
• “If you leave the brain on the table, you are not playing.”
• “I’m like Dr. Seuss. I’ll get a ZOA in a box, I’ll get a ZOA with a fox.”
• “Breathing and autonomics are the same word.”
• “If you think it’s AFIR you missed the show. You are at my daughter’s third
grade magic show and I’m at Vegas with David Copperfield.”
• “Your ab program is likely a neck program.”
• “John Wayne knows how to work serratus.”
• “When subscap becomes subscap, it will give you internal rotation
After an incredibly long 5 days, I finally got the chance to assimilate what I learned from the Prague folks at the C level DNS course.
Despite coming out with a few good exercise tweaks, I left disappointed. I will need some extreme convincing to continue on with their course work.
A man I respect a lot, Charlie Weingroff, likes asking a question regarding interventions:
“Can your treatments beat my tests?”
With that in mind, I looked at DNS’s capability to beat my tests, which are predominately making changes to PRI objective measures.
The answer: Mostly no. I felt a lot of activity with many of the exercises, but if we cannot make measurable changes, then the intervention is not effective. And with the DNS “objective” measures, positive change is attributed visually only.
I don’t care how good your eyes are, you can never know if a joint achieves maximal bony congruency by just watching movement.
Granted, I did get a few things that I will use regularly. But to get 4 or 5 takeaways for a $1000 price-tag, I feel there are better ways to spend money. Like on shawarma and stuff.
Here are my likes and dislikes.
Days 1 & 2 aka DNS A & B
The first two days were predominately review of the A and B courses; looking over developmental positions and reflex locomotion. It was nice to review old concepts, but does it really have to take two days to do?
Spending a full day with DNS creator Pavel Kolar was unfortunately the course low-light. I am sure he is a very intelligent man, but his poor English and general disorganization made his lecture incredibly arduous to follow. Moreover, his thought process for why he does what he does is never explained. He just, does things.
When you have Pavel and Alena apologizing for their lecture, you know that will not be a good sign.
He spoke a lot about training gnostic functions to alter perception and function. Gnostic capabilities include stereognosis, graphesthesia, proprioception, body awareness, etc. He argues that people who excel in these areas will always trump those faster and stronger once development is equalized.
He kept referring to Roger Federer and Jaromir Jagr as basically gnostic kings; and the reason for their career longevity. Each of these players were able to tell weight differences with their respective rackets and sticks to within 100 grams, which is pretty insane. I definitely think there may be some merit in attempting to train these qualities, but we cannot forget about the pattern recognition capabilities that these athletes have. Because they have seen everything before, cues in their brain allow them to react and perform as quickly as possible. This factor definitely contributes to their successes.
He also talked quite a bit about relaxation being the key to performance. When you look at top performers from an EMG perspective, activity stays low until the split second they need to generate the right amount of force. The better you are able to relax, the better you are able to move.
I also have to give Pavel credit in stressing that the brain is DNS’s target. I will attribute this quote to him:
“Structure is always together with the brain, immunology, and endocrinology.”
Reflex Locomotion is the Next Big Thing
Hahaha just kidding.
This DNS area was a major turn-off for me for multiple reasons. Now there were people in class, myself included, that got reactions; but the instructors will tell you these reactions are artificial. So what is the point? How will this change affect function? Do people who have no idea what is supposed to happen get reactions?
And there is no way in hell you can say reflex locomotion is therapeutic for children. There were several patient demonstrations, but what stood out to me was performing RL on a 21 month old baby who was developmentally at about 5 months. Seeing the clinician pin down the child in these positions while she cried the entire time (at least 10-15 minutes) left me angry and near the point of tears for this poor child. The video below was quite similar to what I saw (warning, not easy to watch):
We know what stress does to development, and to stress this child repeatedly throughout the week with reflex locomotion was far from beneficial.
Was There Good Stuff?
Yes, there were a few pretty sweet tricks I picked up that I will use.
The first is a very nice cue for a low-kneeling exercise, which I will dub the rockback press. You will easily be the mayor of Serratus City with this beast.
Another thing I picked up was making quadruped just purely evil. It is all in the setup. Aside from maintaining a neutral spine position (perhaps centrated lolz), the biggest tweaks you can make include loading through the wrist and shins. So for example when performing a bird-dog exercise, instead of lifting the arms and legs, think about putting so much weight through your wrist and shin that your opposite extremities have to leave the ground by necessity.
The Klapp worth Having
We spent a great deal of day 4 working on Klapp crawling, which is basically sliding along the floor on all fours. Once you get the hang of this technique, you will feel muscle activity just about everywhere. Here were the two patterns that I liked the best. I recommend performing these activities with gloves and knee pads
After I did both of these patterns, I was able to hit a legit 3 on the FMS rotary stability, so there may be some legitimacy to these techniques. I will have to play more.
So that is what I got out of DNS C. I definitely got some good ideas amongst the crap over the past three courses, but until they get a little more organized and cut costs, I will not recommend them past A & B. Get the concepts, then move on.
In my short time out I have gotten heavily into the influence that breathing has on the nervous system. Obviously PRI has been my favorite explanation thus far, but the DNS approach had me intrigued. The summit is the first of two DNS courses that I took this past week.
This summit was the first of its kind, and was an amalgamation of many different speakers. Unfortunately, this summit was mostly review and wrought with little innovation. Here are some of the big points I got from a few of the speakers.
“Developmental Kinesiology: Three Levels of Motor Control in Assessment and Treatment of the Motor System” by Dr. Alena Kobesova
There are three levels of development: spinal, subcortical, and cortical
Spinal level of motor control is primitive reflexes; subcortical motor control is core stability; cortical motor control includes individual patterns.
DNS suggests inhibiting primitive reflexes instead of facilitating them for function.
Core stabilization occurs first at 4.5 months development, then locomotion follows.
All movement patterns are either ipsilateral or contralateral. The former develops in supine, and the latter in prone.
“DNS Among Elite Athletes – MLB” by PJ Mainville
Didn’t get much out of this one except PJ dancing around PRI 🙂
Recommended using theratube around the wrist so you can perform hand movements with PNF patterns as such.
“DNS in Gynecological and Obstetrics Disorders” by Martina Jezkova
When in quadruped, the pelvic floor does not create a base for the trunk and had no postural function. The diaphragm acts purely respiratory. Thus, training in this position could potentially restore diaphragmatic respiratory function before throwing on increased demand.
Suck on the thumb to feel the pelvic floor contract.
“Somatovisceral Relations”by Petr Bitnar
Petr spoke very little English, so I had no idea what was really going on.
The upper GI correlates to the cervical spine. Dysfunction in one can affect the other.
The diaphgram has a respiratory, postural, and sphincter function. The diaphragm is your true esophageal sphincter. He had a great video regarding the sphincter function and breathing which I was too slow at acquiring.
“Chronic Pain” by Brett Winchester
Easily the biggest surprise of the show. Was talking about pain being a cortical phenomenon all day. Was so refreshing after a bunch of postural garbage. Saw a ton of Butler and Moseley here.
“Almost every patient with chronic pain carries a bag of shit.”
“The more red, yellow, blue, and black flags a patient has the more readily the clinician is going to wave a white flag.”
“Pain meds are the new white collar drug.”
We should direct therapy at restoring the integrity of cortical information processing.
Brett estimated that 5% of our patients may have cranial nerve dysfunction…perhaps something we should all be checking more often.
A study done in 2011 showed that those with scoliosis have an altered visual midline.
“The Role of Manual Therapies in DNS” by Robert Lardner
Yep, the guy who wrote the Janda book.
“Manual therapy is part of the grooming process in our society.” As he states the work by Sapolsky that shows baboon’s well-being is determined by the amount of grooming they received and if they had stable social relationships.
The kinetic chain is governed by the CNS, so working at one spot affects the entire chain.
Manual therapy’s goal is to normalize input.
Input content and quality will determine output activity and behavior conditioning through neuroplasticity.
“Establishing the Evidence Base: Acceptable Levels of Uncertainty?” by Michael Schneider
Evidenced-based medicine (EBM) is a clinical jazz composed of best current available evidence, clinician experience, and patient values. If any one takes over too much, the ensemble falters.
Whew, I recently finished (and still trying to process) the B level DNS course from the folks at The Prague School. Instructors were Martina Jeszkova and Dr. David Jeurhing. There were a lot of things covered during this 4 day course and I definitely learned a few things. Here are the highlights.
The focal point of DNS is the concept of joint centration, a static and dynamic maximal joint surface approximation. When joint surfaces achieve optimal bony congruency, the muscles surrounding the joint achieve optimal activation and highest mechanical advantage. The reverse is also true. If muscles coactivate properly, then joint centration occurs.
Conversely, if optimal joint centration is not achieved then muscle imbalances occur. The reverse is also true. This change becomes very problematic, as decentration at one joint effects centration at all the other joints. This may lead to decreased performance at best and at worst increased wear on joint surfaces.
Take lower crossed syndrome (or open scissors if you are a DNS fan) for example. Let’s say we had a problem with our lower back. In order to cope with this trouble, we increase lumbar lordosis and decentrate the lumbar spine. See how it affects the surrounding structures. The pelvis anteriorly tilts, which affects length tension relationships to glutes, hamstrings, and hip flexors. Thoracic kyphosis increases as well, affecting the shoulder girdle and cervical muscles. Basically, play with one body region or joint position and see how it affects the others, and you can develop a decent understanding of joint centration’s implications.
No optical contact due to holokinetic movements, which basically means movement due to lack of stability.
Mass extensor pattern in supine.
Mass flexor pattern in prone.
Able to turn head, but cannot lift head off of table.
Optic fixation is constant.
Begins sagittal plane stabilization.
Can begin feeling with arms.
Able to lift the head.
Able to stabilize in sagittal plane.
Functional joint centration of all joints.
Rotates head 30 degrees each direction independent of other spinal movement.
Grasp as far as midline.
Active grasp across the midline occurs, which leads to turning from supine to sidelying.
Chest breathing combined with abdominal/diaphragmatic activation.
Turn from supine to prone.
Can oblique sit onto forearm.
High oblique sit.
Independent steps between surfaces.
Here are a couple vids of the developmental process.
The Integrating Stabilizing System of the Spine
Much of where joint centration begins at the spinal level, and involves the following functional muscle unit activating in a feed-forward subconscious fashion:
Short intersegmental spinal muscles.
Deep neck flexors
Developing proper function of this group is what allows for movement. However, if one of these muscles becomes dysfunctional, the entire complex becomes dysfunctional. Stability is then achieved by substituting with other muscles groups and/or passive structures.
Stabilizing system function is very important as we develop, as lack of this mechanism may lead to abnormal bone structuring. Examples of this would be anterior pelvic tilt, femoral anteversion, spinal kyphosis, etc. These would be deemed utilizing passive structures to increase stability for function.
There are 3 reasons for which stability becomes disturbed.
These patterns are results of poor punctum fixums, which are fixed points to which muscles pull. For example, with supine cervical flexion the fixed point would be T4. If mobile, you may see excessive movement there, hence poor centration. The tests themselves unfortunately require a lot of subjective interpretation in terms of what you see, so I will not give you a demonstration. Here is a brief description of each.
Diaphragm test – seated breathing.
IAP pressure test – Supine breathing.
Trunk & head flexion test – max flexion of cervical spine in supine.
Arm elevation test – Shoulder elevation in supine.
Extension test – Prone head lift.
Oblique trunk flexion – Somewhat cross between an armbar and get-up.
Quadruped rock forward – Watching for winging.
Squat – Duh.
Low kneeling – See below exercise.
Bear position – See below exercise.
Three Level of Motor control
The three levels of motor control are as follows:
1) Spinal/brain stem – neonatal. Think primitive reflexes that we see in babies such as rooting, moro, etc.
2) Subcortical – The first year of life.
3) Cortical – 2-4 years of age.
I will not go into details regarding all the different reflexes; much of these are what you learned in school. This section was one I had some qualms with after recent discussion (i.e. me listening in awe) with Bill Hartman. I do not know that science agrees with maturation in the first year of life being subcortical and reflexive. In order for movement to occur, motor learning and motivation are required. These two are both cortical phenomena. If there were reflexive changes, then should not all babies develop optimally?
Then we went over the “voodoo” aspect of DNS—reflex locomotion (RL). What occurs with this technique is evoking partial motor patterns via afferent stimulations (i.e. pressure) at specific points. These specific points correlate to the support zones that occur throughout the developmental cycle. By pressing on these points, joint centration can be established allowing for motion.
Typically these movements occur more readily with younger children and babies, and sensitivity differs amongst adults. Here are some of the changes typically looked for in RL.
Partial/whole movement patterns
Realize that RL is not a learning/training process and does not teach normal movement. RL achieves muscle activation, stereognosis, and body awareness—prerequisites for movement.
Here are some videos of the positions that I learned in the course from someone who is obviously way better at this modality than I am.
Reflex Turning 1
Reflex Turning 2
The group at my course was generally very reactive and elicited some movements. Even I had a reaction elicited in reflex turning 2. However, it is important to understand that everyone in the course knew what was to be expected; hence I wonder if there is some “Ouija boarding” occurring when we perform these activities.
We did have a couple kiddos come in for treatment as well who had neurological problems. Some “responses” got elicited, though these were very minor and I could not tell very well if these were responses or if the kids were just fidgety. Now, seeing pre and post gait everyone thought there were improvements. Of course, I try to battle confirmation bias somewhat (but it is so damn hard), I had some of my PT colleagues check out the videos. They could neither see a difference nor could they tell which were the pre and post videos. Moreover, it does not help when much of the testing had subjective interpretation. We have to be mindful seeing changes that may not be there, or else you starting looking like the video below.
Now, is there some efficacy in RL? I don’t know. I haven’t seen enough of it to say either way, nor am I good enough at it to elicit regular responses. There is also the time factor that is required to elicit changes, which I have many other techniques that may be just as effective at faster rates. I think the selling point for me will be if I can see nice changes in people with marked neurological deficits. So if anyone has stories, please comment below.
To the instructor’s credit, they state that you will use the active exerciseway more than RL. This is good because this is where I think the DNS bread and butter lies. The exercises have been an excellent adjunct in my practice. Here are the big principles regarding exercise that DNS advocates.
Develop sufficient body awareness by feeling correct and incorrect movement.
Quality over quantity
Perform movements slow and pay attention to how one is moving.
Keep centration throughout.
The exercises utilize correspond with the various developmental positions, so here are some examples that I have been utilizing and playing with.
4.5 month breathing with band pulldown courtesy of my man Bill Hartman with the wonderful Eric Oetter.
3 month prone with head turns
4.5 month reach
6 month supine breathing
7 month low oblique sit with press
Roll to 8 month oblique sit.
Low kneeling plank
Tripod to bear to squat
TRX sit to ½ kneel
We also learned a great way to cue squats to increase pelvic floor activation, which I describe in the video below.
We also had some off-topic discussion with quadruped foot versus tripod/short foot, which I outline in the below video.
Now I realize that there were some DNS concepts that I knocked, however I will say that the exercise portion of things is very good. Our nervous system is looking for novel input, and I feel the exercises are a great way to provide this. We all developed too, so neurologically these positions are somewhat familiar albeit challenging at time. What is more, DNS exercise does an excellent job of integrating all the body segments into moving as one unit as opposed to training/rehabbing specific body segments. I can appreciate that the folks at the Prague School have taken many different concepts and tied them together into one unit.
So should you take their courses? I say yes. I still learned a great deal in both A and B despite my gripes, and I plan on taking C this fall. So check out the Prague school and learn some good skills.
I also would like to shout out my good friend/fellow mentor PT/cameraman/all around good guy Scott Passman for taking some of these videos, as he put in great effort to make them look good.