“If breathing is not normalised – no other movement pattern can be”- Karel Lewitt

In recent conversations with students in my office and with colleagues curious to learn more about how Dynamic Neuromuscular Stabilization (DNS) works “on the ground” in practice, I have attempted to bring together an overview that can be readily understood for these folks. Full disclosure…at this point (2-17-2013) I have completed DNS training through the “C” level of clinical practice and “Sport” courses 1 &2. This level of training does not qualify me to be an instructor in the DNS system, so all of my musings here should be taken with a grain of salt and are trumped by those who have received those more advanced qualifications. Therefore, think of this post as my own personal musings as I attempt to integrate the work into my sports-injury/rehab-focused practice of chiropractic and take what you will from it. The graphic below was my attempt to explain the flow of common musculoskeletal injury and dysfunction through the DNS lens. Below that, we’ll examine each of these points so that we can see how this pattern recurs with our patients. In future posts, we may refer back to this post to help frame specific Case Studies.

1. Apical Respiration-When Stress Somatisizes

One of the primary tenets of DNS is the importance of breathing stereotype. The effects of inefficient respiration carry over to other disciplines of health care such as cardiology (1,2,3), gastroenterology (4), pain management (5) and psychology (6) as well. In the DNS model, breathing patterns that are high in the chest, rapid and shallow (apical) can result in altered position of the diaphragm. (7)

CONCLUSION: Patients with chronic low back pain appear to have both abnormal position and a steeper slope of the diaphragm, which may contribute to the etiology of the disorder.

2. Disruption of Native Spine Stabilization Strategies

Using the muscles of the ‘deep core’ (multifidii, transversus abdominis, pelvic floor and diaphragm), spine stabilization can occur via improved intra-abdominal pressurization. (8,9)  This video by Gray Cook, PT speaks to this topic from a tangential viewpoint.

3. Adaptation of High Threshold Stabilization Strategies

When optimum stabilization strategies are not available, phasic muscles typically used for prime movement are used to both move and to provide alternate stabilization strategies. These strategies for movement often result in joint de-centration which leads to less-than-optimal performance. If loads are too high, too intense, or too frequent joint degeneration and tissue failure may be the result. Charlie Weingroff, DPT speaks to this below.

4. Structural Adaptations of Myofascial Elements

Langevin also proposes a central sensitization component in this paper, modeled on conversations with Lorimer Moseley.

Langevin and other researchers have shown that the fascial remodeling occurs in those with chronic low back pain (CLBP) and that the lumbodorsal fascia of those with CLBP is 25% thicker than in controls. (10,11)   The presence of  ‘tunnel syndromes’ involving superficial neurology has been well described. (12)  Janda’s Crossed Syndromes spoke to inhibition of agonists in the presence of shortening of antagonists. This pattern was later updated by Gray Cook and Mike Boyle and is now referred to as the Joint by Joint Approach. As synergistic muscles are re-tasked to shoulder the load left by inhibited muscles, remodeling of the muscle can change its texture, pliability and result in fascial remodeling in the involved muscles. This may also result in superficial entrapment of local superficial nerves and result in local neuralgia in the absence of joint or muscle injury. This point in the process is where manual therapy has the most direct impact and allows bodyworkers an in-road on understanding and treating patients using a functional approach.

5. Tissue Failure/Degeneration and Diminished Performance

Langevin et al. Reduced thoracolumbar fascia shear strain in human chronic low back pain. BMC Musculoskeletal Disorders 2011, 12:203

Langevin also theorized in her paper on thoracolumbar fascia,

“Possible explanations for reduced thoracolumbar fascia shear strain during passive trunk flexion in LBP include abnormal patterns of trunk muscle activity and/or intrinsic connective tissue pathology.” (13)  

In the DNS model, we may see common injuries develop around the hip, knee, shoulder and elbow in response to the aberrant loading of those joints in these scenarios. Rather than structure-focused treatments to address the site of pain, practitioners assess movement and stabilization strategies and address those non-painful dysfunctions to effect long lasting beneficial changes. Similarly, in the FMS model, we screen for asymmetrical movement patterns and correct the non-painful dysfunction.  These last 2 areas we will save for further explorations with case studies to demonstrate the clinical applications of the combined structural-functional methods. We will also show those corrective exercise interventions featured on MyRehabExercise.com.

References:

1. Anderson DE, et al. Regular slow-breathing exercise effects on blood pressure and breathing patterns at rest. Journal of Human Hypertension. In press. Accessed Nov. 9, 2010.
2. Gavish B. Device-guided breathing in the home setting: Technology, performance and clinical outcomes. Biological Psychology. 2010;84:150.
3. Schein MH, et al. Treating hypertension in type II diabetic patients with device-guided breathing: A randomized controlled trial. Journal of Human Hypertension. 2009;23:325.
4. Bryan T. Green, MD; William A. Broughton, MD; J. Barry O’Connor, MD, MS(Epid). Marked Improvement in Nocturnal Gastroesophageal Reflux in a Large Cohort of Patients With Obstructive Sleep Apnea Treated With Continuous Positive Airway Pressure. Arch Intern Med. 2003;163(1):41-45. doi:10.1001/archinte.163.1.41.
5. Busch V, Magerl W, Kern U, Haas J, Hajak G, Eichhammer P. The effect of deep and slow breathing on pain perception, autonomic activity, and mood processing–an experimental study. Pain Med. 2012 Feb;13(2):215-28.
6. Alicia E. Meuret, David Rosenfield, Anke Seidel, Lavanya Bhaskara, and Stefan G. Hofmann. Respiratory and Cognitive Mediators of Treatment Change in Panic Disorder: Evidence for Intervention Specificity. J Consult Clin Psychol. 2010 October ; 78(5): 691–704.
7. Kolar P, Sulc J, Kyncl M, Sanda J, Cakrt O, Andel R, Kumagai K, Kobesova A. Postural function of the diaphragm in persons with and without chronic low back pain. J Orthop Sports Phys Ther 2012;42(4):352-362.
8. Hodges PW, Eriksson AE, Shirley D, Gandevia SC. Intra-abdominal pressure increases stiffness of the lumbar spine. J Biomech. 2005;38:1873-1880.
9. Hodges PW, Cresswell AG, Daggfeldt K, Thor- stensson A. In vivo measurement of the effect of intra-abdominal pressure on the human spine. J Biomech. 2001;34:347-353.
10. Langevin HM, Sherman KJ. Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms. Med Hypotheses 2007;68(1):74–80. 
11. Langevin HM, Stevens-Tuttle D, Fox JR, Badger GJ, Bouffard NA, Krag MH, Wu J, Henry SM. Ultrasound evidence of altered lumbar connective tissue structure in human subjects with chronic low back pain. BMC Musculoskelet Disord. 2009 Dec 3;10:151.
12. Pecina MM, Krmpotic-Nemanic J, Markiewitz AD. Tunnel Syndromes: Peripheral Nerve Compression Syndromes. CRC Press, 2001.
13. Langevin et al. Reduced thoracolumbar fascia shear strain in human chronic low back pain. BMC Musculoskeletal Disorders 2011, 12:203
    

This is the third installment of our series on the ‘care and feeding’ of the injured lumbar disc. In Part 1 we discussed the structural pathology (the broken stuff) and in Part 2 we started a discussion of the functional pathology (why stuff broke). Today, we’ll continue the functional discussion assuming you’ve done some pre-reading or have an understanding of the Joint By Joint Approach. If you don’t, follow the link and brush up. Also, these approaches and the exercises associated with each stage of the rehab process are represented in the library of detailed functional rehab exercise here at MyRehabExercise.com. You can’t use them to help teach your patients and clients unless you’re a member. Membership is inexpensive ($19.99/mo), 30 day trial for $1 and you can discontinue service anytime. Follow the links to the right to sign up.

If you don’t have an office set up to instruct your clients or patients in rehab exercise, or if you just don’t  feel comfortable customizing the exercise Rx yet for disc injury, check out FixYourOwnBack.com. There, you can just refer your patients or clients with disc injury, disc bulge, herniation, sciatica and for $9.99/mo they can receive the self-help education and  rehab Rx that is being discussed in this blog series re: management of the lumbar disc injury.

The Plan–“Plan the work, then work The Plan”

Once we have an injured lumbar disc, The Plan (as it’s referred to on FixYourOwnBack.com) is as follows:

1. Stop faulty movements and postures that “pull the scab off” of the healing disc
2. Learn disc “First Aid” using McKenzie methods to assist in healing and control pain
3. Use McGill’s Big 3 and DNS methods to stabilize the lumbar spine
4. Improve mobility in the T-spine and hips to spare the spine
5. Use FMS-based corrections to integrate stability and mobility achieved in #3 and 4 above into long term sustainable movement patterns
6. Improve strength in the muscles necessary to perform #5 above
7. Improve agility in those sustainable movement patterns to help with resilience when life throws a curve
8. Incorporate sport specific skills to help manage disc injury and recurrence

The Stiff Upper Back

Modified Sphinx-MyRehab members can click here to view the video

The Creaky Hips

As the shortened flexors’ insertion onto the lesser trochanter persists, the femur shifts anteriorly in the acetabulum. When that individual squats deeply, the acetabular labrum gets munched and sometimes the repetitive loading of this imbalanced hip into deep flexion can result in bony changes now referred to as femoral acetabular impingement (FAI). For more info on FAI, check out this link to Craig Liebenson’s blog. Learning how to test for this is helpful, as an Xray can point to whether that patient should be in an orthopedist’s office. However, all anterior hip pain is NOT FAI, and the condition starts as a soft tissue issue. Catching it early in the progression means you can head off not only a hip replacement years later but also the well-meaning FAI surgery!

Charles Scott Sherrington’s Law of Reciprocal Innervation won him a Nobel Prize in 1932 for describing the neurological relationships between agonist and antagonist muscle groups. Stated simply, when a muscle contracts, its antagonist on the other side of the joint is reflexively relaxed to allow joint movement to occur.  Several decades later, Czech neurologist Vladimir Janda coined a corollary to Sherrington’s Law which states that when a muscle’s resting length has been shortened, it’s antagonist will be reflexively inhibited. Around the hip joint, the tight hip flexors inhibit the large muscles of the buttock…the glute max and the glute med. This condition in the hips has been referred to in Janda circles as part of the Lower Cross Syndrome, and years later by Stu McGill as ‘gluteal amnesia’.

Tactical Frog-MyRehab members can click to view the video.

FixYourOwnBack members can find this as part of Chapter 5-Integrating Stability and Mobility

Soft Rolling-Lower, From MyRehabExercise video tutorial library

Hard Rolling–from MyRehabExercise video tutorial library

Tall 1/2 Kneeling Chops–from MyRehabExercise video tutorial library

Pallof Presses–from FixYourOwnBack video tutorial library

Click Here to Get Access to This Disc Injury Rehab Progression at FixYourOwnBack.com

is a sister site with…

Part 1 of this multi-part posting on lumbar disc injury diagnosis and management discussed identification of the structural issues associated with the injury. Next post we’ll look at some of the finesse points that trainers and clinicians can address to improve long term function in the lumbar spine. Today we’ll look at the functional aspects.  How do we see a disc injury before it manifests as a fully blown sciatica/radiculopathy event or,…

What are the functional clues to impending disc injury?

Lab studies show that endrange loading of the lumbar discs into flexion in the presence of compression is the quickest way to cause a disc to herniate in the low back. More often than not in my experience, this represents the end result of long term habitual lumbar hinging, until the fateful day when the patient bent forward to pick up ___________(fill in the blank) and felt the searing pain in the butt and leg. Single injury events do occur, usually as a slip and fall onto the butt or as a poorly executed heavy lift. I can’t tell you how many initial onset histories in guys start with, “My first back injury occurred in high school in the weight room after football practice when me and 2 friends (always 2 friends, and poor grammar) decided to see who could back squat the most weight.” Often, they remember a ‘pop’, and back pain, with some sciatica later. Some researchers have said they can hear that ‘pop’ in the lab as the endplate fractures when they load the motion segments to failure in flexion/compression in pig spines. The research of spine biomechanist, Michael Adams, PhD suggests that that endplate failure is frequently the cause of the altered motion in the vertebral segment over time that results in disc degeneration.

If this patient walks into your clinic, studio or gym, that lumbar hinge is what you’re looking for. If they are acute with radicular symptoms and you try a multisegmental flexion assessment per SFMA, you’re a cruel bastard. The seated slump test from the previous post, and the quadruped sit back assessment as in the photos below from Stu McGill’s Low Back Disorders will yield your lumbar hinge under less provocative loading.

Start in quadruped

Look for the hinge as they sit back toward the heels.

Fix that hinge by quickly training them to hip hinge and box squat so that they don’t hurt getting up and down from the chair to the exam table. Video tutorials for these are available to subscribers of MyRehabExercise.com to send to their patients or clients. If you don’t feel comfortable in your clinic setting or your bodywork studio confidently instructing your patients or clients how to do this, I’ve uploaded these as free material on the FixYourOwnBack.com site. Use that as a resource for your patients or clients to learn more about their disc injury.

If you’re a trainer and your client has this history, put down your cell phone and stop texting while your client is squatting, rowing, deadlifting, etc and make sure that they aren’t hinging in the lumbar spine while performing those movements. If you’re doing Boot Camp types of movements like Burpees, Mountain Climbers and Squat Tosses with medicine balls, make sure they don’t hinge with these movements. (I think Boot Camp exercise vigilance might require a separate post now that I think of it). Trainers can help buttress the lumbar spine during squatting by cueing the client to use the lats by ‘bending the bar’  and cueing the glutes by pushing their knees in and having the client resist strongly by pushing the knees out (As of November 2014, we’ve updated these cues after seeing them more effective in one of the best powerlifting gyms in the world. Find that info on Chapter 9 of The Plan, available to subscribers of FixYourOwnBack.com). If this info is new to you, then you need Stu McGill’s other book, Ultimate Back Fitness and Performance. Seriously…go now and get it…we’ll wait until you get back!

The typical disc presentation is flexion-intolerant, but many of these folks also complain that extension hurts too when you stand them up and ask them to bend backwards. This is important to know because you need to repeat that extension in the prone position. You also need to repeat it several times and ask if the repetitions are less painful.

If they are, you’re on the right track and need to continue the extensions with McKenzie protocols. Does that mean you’re done with the rehab? NO!

The following quotes are from member feedback at FixYourOwnBack.com in the Discussion Forum:

“I now understand why 3 months of McKenzie exercises (post position) 8×10 reps a day prescribed by my last PT caused new pain and symptoms.”

“I have been taught to do the Dead Bug by four physical therapists over the past three and a half years. Doing it the way you explained in your video is a completely different experience and makes it a completely different exercise. Thank you for the in-depth explanation.”

I’ll also share a recent patient presentation too: 29 y.o. female 2nd year med student and former Division 1 soccer player presented with low back and leg pain 3 weeks after discharge from PT where she received McKenzie (MDT) therapy. Once her pain improved, she was discharged to normal ADLs. Her first rec league soccer match ended early with raging leg pain and weakness after a long cross field kick.

I’m a huge fan of MDT and use it daily in my own practice, and that approach did not fail with any of these cases. It did fall short of rehabilitating the injuries of these patients. To paraphrase the common question in all of these individuals:

Is There Life After McKenzie?

Full disclosure, I am not MDT certified but learned this approach in my DC training, through reading the literature concerning it and I employ it daily with my cervical and lumbar disc patients. The way I use MDT and frame it to my patients is as a first aid kit. I know of nothing else that allows a lumbar disc patient quicker self help pain relief for disc pain and sciatica. To my mind though, it only gets the patient to Square 1 of the rehab process.

Once the person is out of pain, that’s when the fun starts! I break out McGill’s rehab protocols, Janda’s Movement Pattern Assessments,  DNS assessment, SFMA algorithms, Liebenson’s Mag 7, etc and customize an exercise program for them that borrows from all of these schools of thought.  Once your toolbox is deep and you’re familiar with these methods they blend wonderfully for the lumbar disc patient. Despite all of these customizations though, probably 90% of these lumbar disc patients have a very similar take home plan.

1. Use McKenzie prone press up to control pain
2. Correct transitional movement flaws and posture faults to stop ‘picking the scab’
3. Stabilize the lumbar spine by building endurance in sagittal and frontal planes/incorporating proper breathing stereotype
4. Correct mobility deficits that likely exist in the T-spine and hips, possibly ankle
5. Build strength
6. Build agility
7. Build power
8. Address sport specific issues pertaining to the lumbar disc

Does Everyone Need An Individual Assessment?

Wouldn’t that be nice? While I would love to see everyone receive an excellent functional assessment,  but so many folks are suffering from lumbar disc injury and it is responsible for such a drain on public health that I think we need to address this from a public health perspective.  We need  low cost ways to get most of the people suffering from disc injury educated about what not to do, what they should do more of, and how to incorporate exercise into their self treatment without hurting themselves. Once folks get feeling better, they will need guidance and excellent exercise instruction. Are you qualified? If not, why not? And that leads us to another important question:

What Will You Do In Your Next Career When Your Patients Find Out That They Feel Better After Working Out Than After Leaving Your Office?

Those of you who are savvy to Functional Rehab and who are members of MyRehabExercise.com, know that all of those approaches above are already available to you on that website to prescribe those tutorials by sending your patients an email link to their customized prescription.  However, what if you’re a bodyworker, or massage therapist and you don’t feel comfortable taking your relaxed, naked patients through rehab exercise instruction after a massage? I just released another site to help those folks distinguish your services by including exercise. Refer your clients and patients to FixYourOwnBack.com where they can get free education and for much less than they would pay for an office call, they can get the exercise plan above laid out for them as video tutorials. Next post, I’ll cover deeper functional approaches to managing the lumbar disc patient by decoupling the hip movement from spine movement, and improving mobility in key areas. Cheers!

AUTHOR’S NOTE: TO SEE THE OTHER PARTS OF THIS SERIES CLICK THESE LINKS FOR PART 2 AND FOR PART 3.

Can you recognize a disc patient when they walk into your office? The reason I ask is because a sizable number of the chiro students that come through my office find it difficult. The MDs that I see in the office don’t seem to know it when they see it…or even when they have it! It was also enlightening a year ago while working with Dr. Craig Liebenson to see the DC/PT crowd in the 80+ audience struggle with a disc presentation.

I’ve wondered about why this seems to be obtuse to many clinicians and I think that it is ironically due at least inpart, to the way we ingest the literature regarding back pain. An artifact of the RCTs on back pain is that clinicians are trained to diagnose disc injury only in the presence of frank neurological signs. After all MRIs frequently demonstrate disc pathology in the asymptomatic population and that’s the only way we can be sure the disc is injured, right?  Recently, one of the world’s best known, and most published spine researchers was rumored to have said (paraphrasing) “Randomized Controlled Trials (RCTs) on back pain should be banned because they’re so f@#$ed up“‘. What on earth did this researcher mean? RCTs are the gold standard of evidence-based practice! In the post-modern, evidence-based world, shouldn’t we be on bended knee to the “evidence”?  As a clinician who has taken part in some of those major clinical trials I would say yes…but…

Let’s review the definition of evidence based practice as defined by Joel Sackett. It is defined as practice based on the following 3 components:

1. The best available current scientific evidence.
2. The clinical expertise of the provider.
3. Patient choice in their care.

Here is a quote from Sackett that I think is germane to this blogpost and speaks directly to the 3rd point above and to the insecurities of many who are afraid of EBP:

“Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient.”

RCTs are limited by the questions they ask and by the populations they ask them of. For instance, some cynically note that specific exercise has not been shown to be beneficial for back pain. The problem is that historically, the cohort in LBP studies has mostly been heterogeneous and doesn’t account for either what type of exercise is prescribed, or what type of subgroup of back pain is receiving the prescription.   Jeff Hebert et al, described these subgroups nicely along with effective treatment modalities for the subgroups in this paper.

I feel another misinterpretation of the literature is regarding the diagnosis of disc injury and radicular presentation (sciatica). Many clinicians are trained to only make the diagnosis of disc injury if neurological symptoms are present (numbness, tingling, pain, motor weakness in a dermatomal distribution). It used to be that we’d rely on MRI to make the diagnosis but now know that many asymptomatic people have disc pathology on MRI.  However, a functional approach takes account for a continuum of an injury. I feel that only calling a disc injury a disc injury when one has neurological signs and symptoms is like ignoring the smell of smoke before the fire over takes you. I also feel that failure to identify disc injury prior to neurological deficit has a major effect on the public health and on cost of health care.  Reflecting back to point 2 above, the clinical expertise of the provider, I’d like to take an opportunity to describe how I address disc patients now after treating them daily in clinical practice for 10 years.

So how do we detect a disc injury before it causes neurological signs?  By assimilating multiple clues from the patient’s history, physical exam and neuro exam as well as any imaging findings.

History

Family history is very important here as Videman and Battie’s research suggests that a genetic component is at play here, and seems to involve some polymorphisms that result in weaker collagen formation and subsequent disc degeneration (may account for 30-70%!). Also important are the activities of daily living that worsen pain. The hallmarks that I’ve seen are:

• Pain in transition for sitting to standing
• Pain when rolling over in bed
• Pain getting in and out of cars
• Pain putting on shoes/socks

This video shows a quick correction of these movement patterns so that a disc patient can quickly be taught how to stop hurting themselves. It is part of the free educational video area of FixYourOwnBack.com.

Examination

In the functional rehab world, it is currently fashionable to poo-poo structural issues in diagnosis and management of patients. My opinion is that this represents an adolescent trend in healthcare. We have errantly over-relied on structural cause for pain and dysfunction for far too long. While the research of folks like Ron Melzack,  Lorrimer Moseley and David Butler has rightly brought our attention to the ‘Neuromatrix of Pain’, I fear that we may be throwing the baby out with the bath as we rush to disregard structural pathology.  In an interview I did with Michael Adams, he had the following quote re: research on disc injury:

“Most people producing the research concerning back pain don’t talk about disk injury. It’s almost a shock to find someone take a breath and actually talk about disc injury.”

To bring the discussion back to the exam of the back pain patient, the current evidence suggests a cluster of orthopedic tests is best to help identify lumbar disc injury and whether or not that disc injury compromises a nerve root. Below is a video I did putting these 2 tests together in the way that I perform them in clinic for expediency and accuracy. Additionally, I add a functional test for lumbar extension borrowed from the McKenzie folks to help identify quickly how to treat the patient both in the clinic and with home exercise.

Quick overview of the 3 tests :

• Slump tells you it’s a mechanically compromised disc
• SLR tells you if the compromised disc is affecting a nerve root
• McKenzie prone press up (Sphinx in yoga) shows the way for treatment

• Multisegmental movement offers clues but poorly tolerated in disc pt
• McGill’s quad sit back shows the hinge
• Squat/rise shows contributing global movement pattern
• Hip flexor endurance test
• Leg raise per FMS

For those interested in seeing the combination of structural and functional approaches as it applies to disc injury, please visit FixYourOwnBack.com. There you will find an organized, self-help exercise program based on the outline modelled here. Arranged in an innovative, interactive chapter book format, users can work at their own pace to address the mobility, stability, integration, strength, agility and power components of complete rehab of the lumbar disc injury.