Dynamic Neuromuscular Stabilisation
Dynamic neuromuscular stabilization (DNS) is based on principles of developmental kinesiology, focusing on the maturing human locomotor system. The approach views people with certain types of pain and dysfunction as having defects in neuromotor programming. This dysfunction can arise from internal reasons or external factors like accidents, leading to changes in movement patterns, motor behavior, and posture. DNS also has applications in improving sporting and occupational performance.
DNS was developed by Professor Pavel Kolar (physiotherapist) in the Czech Republic, who was influenced by three other prominent Czech professors: Vojta (pediatric neurologist), Janda (neurologist), and Lewit (neurologist). Kolar continues the work of these pioneers, integrating their knowledge about the locomotor system developed over the last 100 years. DNS is practiced widely in many parts of Europe in mainstream clinical centres but is largely unknown in New Zealand except within Musculoskeletal Medicine. It is a functional approach, contrasting with the more traditional structural biomedical approach. It is an active therapy, where the patient is given home exercises guided by the clinician. The core aim is to restore the body's genetically programmed motor patterns, rather than trying to change them with potentially unsuitable exercises often seen in gyms.
Developmental Kinesiology
Ontogenesis refers to the development of motor functions postnatally. The locomotor system is genetically determined and centrally programmed, unique to each species. Locomotor development occurs with the maturation of the CNS; it is not learned. Unlike many mammals born with relatively mature motor systems, human neurological and locomotor systems are immature at birth. This extended maturation period, roughly 11 months to walking, is due to our evolutionary path favouring larger brain development. While motor patterns and balanced muscle activity are controlled by the CNS according to a genetic program, it's estimated that while around 70% of individuals follow normal programmed locomotor development, about 30% may experience abnormal motor development resulting from genetic abnormalities, injury, or abnormal behaviours/habits (e.g., a ballet dancer's "turnout").
As the central nervous system (CNS) matures, postural foundations are established through genetically programmed, specific motor patterns that emerge at certain developmental milestones. Muscles are activated in postural patterns automatically, influenced by factors like visual orientation and the child's emotional needs (e.g., seeing a parent, reaching for a toy). Watching a child develop from birth to walking reveals how this program unfolds. There are three levels of postnatal CNS maturation corresponding to three levels of sensory-motor control:
Neonatal Period (Birth to ~3 months): Spinal and brain stem control systems dominate. There's functional and structural immaturity, lacking balance and postural function. Deep spinal stabilizers lack coordination, leading to excessive asymmetry (moving the head moves the whole body), anterior pelvic tilt, rib cage flaring, and elevated/protracted shoulders. Primitive reflexes (e.g., Moro, sucking) are present.
Subcortical Integration (~3 to ~18 months):
Postural foundations develop with synergy, coordination, and timing. Fixed stabilizing points, or "Punctum Fixum", emerge in the trunk and pelvis, allowing larger muscles to work effectively and reducing asymmetry. The deep stabilizing system coordinates, enabling progression from prone/supine (sagittal plane stabilization) to rolling (using oblique chains), crawling, kneeling, squatting, and walking.
- For instance, by 3-4 months, a baby lying supine with legs in the air achieves good sagittal plane stabilization, a primary position for rehabilitation.
- By 6 months supine, the baby can typically bring hands and legs together, touching the feet, indicating further maturation. Chest breathing develops, alongside maturation of the orofacial system, which is a prerequisite for chewing and speech.
- Rolling over utilizes contralateral patterns and oblique chains, similar motor patterns used by athletes like shot putters.
- Around 7.5 months, the "oblique sitting" position emerges, initially supported on the elbow/forearm, progressing to an open hand. This position facilitates trunk straightening in the frontal plane. The pincer grasp also develops around this time, related to the child reaching in the oblique sit position.
- Gaze fixation and somatosensory input develop, integrating environmental information. Primitive reflexes are inhibited.
Cortical Integration (2 to 6+ years): Motor learning emerges with selective movement, fine motor skills, agility, and dexterity. External rotation in abduction of the shoulder is one of the last movements to fully develop, around age 4, and can be one of the first abilities lost with dysfunction.
While ideas about "ideal posture" vary, developmental kinesiology (ontogenesis) reveals a genetically determined ideal posture achieved automatically with healthy CNS maturation. Balanced muscle activity between agonists and antagonists, controlled by the CNS, ensures joint centration and normal joint development. The fundamental locomotor program remains, for example, the squat of a 12-month-old utilizes the same program as a powerlifter's loaded squat.
The Integrated Stabilising System of the Spine
The ISS integrates deep stabilizing muscles with larger muscle groups. The deep stabilizing system includes the diaphragm, pelvic floor, the entire abdominal wall (all four layers acting together), multifidi, and deep neck flexors. When this system functions with synergy, coordination, and timing, the diaphragm descends before purposeful movement initiates. This increases intra-abdominal pressure, activating the deep stabilizing musculature to create a fixed point (Punctum Fixum), allowing larger muscles (like rectus femoris) to work efficiently off this base ā a "feedforward mechanism".
The diaphragm is key, acting as the "team captain". It has three functions: respiration, stabilization, and gastro-oesophageal sphincter function. Anatomically linked to transversus abdominis, it works with the pelvic floor, abdominal wall, iliopsoas, and multifidus. The diaphragm and pelvic floor are partners, needing parallel alignment for optimal respiratory, postural, and sphincter function. Poor posture (e.g., elevated ribs from chest breathing, anterior pelvic tilt from tight iliopsoas) disrupts this parallel alignment and coordination. Diaphragm function is highly integrated with stabilization; lifting an arm or leg automatically increases diaphragm activation and excursion.
This DNS "core stabilization" differs significantly from bracing. Bracing is concentric abdominal activation (outside-in), providing stability but limiting movement support. DNS stabilization works from the inside out via intra-abdominal pressure, facilitating safe movement, load management, and coordination of breathing and stabilization. It's dynamic, maintaining intra-abdominal pressure during movement and load changes, unlike static stabilization. Never consciously "suck in" the abdomen, as this inhibits proper diaphragm function. Similarly, avoid pushing the back flat.
Postural function precedes and follows movement; it's dynamic, ensuring trunk, spine, and pelvic positioning during activity. Controlled subcortically, it allows anticipatory brain activity for efficient movement. Suboptimal ISS function doesn't prevent movement but can limit performance, overload passive structures (leading to potential nociception ), and increase injury risk. Injury or pathology impacts this entire system, altering movement and posture segmentally and globally. Dysfunction can arise from reactions within the CNS, leading to segmental issues (muscle, joint, skin changes) and postural chain reactions affecting alignment.
Functional Rehabilitation Principles
Key DNS rehabilitation principles include:
- Restore diaphragm breathing and function
- Restore dynamic neuromuscular spinal stability
- Activate deep neck flexors
- Restore upper thoracic extension (T4) using deep flexors and extensors of the neck
- Restore scapula stability
- Improve cervical, thoracic, and shoulder girdle mobility
- Restore lower limb functional stability and iliopsoas function
- Address muscle imbalances, such as releasing tight postural/tonic muscles (developmentally older muscles prone to shortening, e.g., upper trapezius, pectorals, iliopsoas ) and strengthening weak phasic muscles (developmentally younger muscles prone to weakness, e.g., lower trapezius, serratus anterior, gluteals ).
| Tonic Muscles
Developmentally older Tension and shortening |
Phasic Muscles
Developmentally younger Weakness and wasting |
|
|---|---|---|
|
|
Joint Centration
A core concept is achieving functional joint centration (neutral joint positions) through optimal ISS function. Centration offers:
- Optimal loading with mechanical advantage.
- Greatest interosseous contact for load transference.
- Ideal agonist/antagonist balance for maximal muscle pull and passive structure protection
- Ensures normal joint development. Abnormal brain function can lead to abnormal morphology due to poor centration.
Assessment and Treatment Approaches
The DNS approach focuses on assessing and training inefficiencies in the deep stabilising system. It aims to facilitate and reintegrate the hardwired genetic locomotor programme and utilises the positions of the developmental milestones. As adults the locomotor programme can become corrupted through postural habituation, repetitive motions, past injury, and pathological central nervous system maturation. Despite corruption, the potential for facilitation is still there.
Ideal core stabilisation corresponds to the muscular coordination of a 3 month old baby with the baby in a supine position with the hips flexed. Training instructions include maintaining a neutral (caudal) chest position, coordination of the diaphragm and pelvic floor, cylindrical activation of the abdominal wall, maintaining a neutral neck position, avoiding lordosis of the lumbar spine, actively maintaining a neutral hip position, and directing the patient's breath as far as the inguinal region and lateral dorsal aspects of the abdominal wall.
The clinician can use different methods such as manual therapy, cueing, and specific DNS active exercises to help facilitate correct activity of the deep stabilising system. Exercises are based on developmental kinesiology. They allow training of muscles during physiological function. They automatically activate ideal stabilisation function at the subcortical level.
Assessment
- Main article: Dynamic Neuromuscular Stabilisation Examination
Assessment involves comparing the individual's patterns to developmental norms. This includes evaluating:
- Compare individual postural locomotor patterns with developmental patterns
- Functional centration of individual segments with the ability to maintain individual body segments in a neutral centred position
- Evaluation of dynamic postural trunk stabilisation and muscle coordination responsible for stabilisation of the entire core
- Quality of spinal stabilisation of the spine, chest, and pelvis
- Dual role of the diaphragm in stabilisation and respiratory function
- Distribution of activation between superficial and deep stabilising muscles
- Symmetry and timing of activation of the spinal stabilisation muscles
- Adequacy of muscle activity under load
- Muscle compensatory mechanisms
- Spread of muscle activity to other segments of the body
Specific Examples:
- Trunk and Neck Flexion Test: The patient attempts to lift the head and trunk. Assessment focuses on the activation of deep neck flexors and stabilization of the lower ribs and thoracolumbar junction. Poor patterns might involve excessive use of superficial neck muscles or lack of core stabilization.
- Correct activation: head position involves activating deep neck flexors, often practiced against a wall initially.
- Extension Test (Prone): The patient lifts the head, extending the spine slightly. Assessment looks at the coordination between paravertebral muscles and abdominal muscles, shoulder blade position, and the spinal segment where movement initiates.
- Correct activation: Balanced activity between back and lateral abdominal muscles. Movement ideally initiates around T4, which acts as a transition segment and punctum fixum. Shoulder blades should remain stable.
- Insufficient stereotype/Mistakes: Common errors include head retraction, shoulders lifting towards ears, excessive shoulder blade retraction or elevation/adduction of upper angles and abduction of lower angles (indicating upper/middle trapezius dominance over lower trapezius), excessive thoracic kyphosis or lumbar lordosis, and squeezing the buttocks.
- Test on All Fours: The patient shifts weight slightly forward. Assessment focuses on shoulder blade position and stability. Poor patterns may show adduction, elevation, or excessive rotation of the scapulae, indicating muscle imbalances (e.g., weak lower trapezius, tight upper/middle trapezius).
Treatment
Treatment utilizes methods like manual therapy, cueing, and specific DNS active exercises based on developmental positions. These exercises train muscles physiologically and activate ideal stabilization subcortically. Reflex Locomotion Stimulation, using specific stimulation points identified by Vojta, can activate innate motor patterns (like rolling) even in adults, helping restore the program. This is a powerful tool for quickly changing diaphragm and related muscle function without conscious patient effort. Clinicians must listen carefully to the patient, understanding their "language" of pain and dysfunction. Observation is key, just as it was for pioneers like Vojta, Janda, Lewit, and Kolar.
Specific examples:
- Exercise Example (Oblique Sit): Starting supported on the elbow, progressing to the forearm to exercise serratus anterior stabilization, maintaining shoulder alignment perpendicular to the spine axis, avoiding scapular elevation. Difficulty can be increased with trunk rotation or adding resistance. One of the important aspects of this exercise is that it is closed kinetic chain.
- Reflex Locomotion Stimulation: Using specific stimulation points identified by Vojta, clinicians can activate innate motor patterns (like rolling) even in adults, helping restore the program. This is a powerful tool for quickly changing diaphragm and related muscle function without conscious patient effort.
- Manual Techniques: Techniques like Post-Isometric Relaxation (PIR), Myofascial Release (MFR), joint mobilization (e.g., C0/1, C1/2, thoracic segments, SC/AC/GH joints, 1st rib), and trigger point deactivation can be used to address restrictions and muscle imbalances identified during assessment. Examples include clavicular release, medial scapula release, and addressing pectoral/subscapularis tightness.
Ideal core stabilization mirrors a 3-month-old baby supine with hips flexed. Training cues include maintaining neutral chest/neck/hip positions, coordinating diaphragm/pelvic floor, cylindrical abdominal activation, avoiding lumbar lordosis, and directing breath towards the inguinal region and sides/back of the abdominal wall.
Applications
Sporting Applications
Sport performance relates to power, strength, speed, and endurance. Sport technique is also required, and in order to facilitate technique, the athlete needs optimal postural foundations, optimal movement quality, coordination, and good cortical function with respect to body awareness. There is maximum demand on muscle activity, range of motion, loading of passive structures, and increased demands on the respiratory system. Training allows the body to adapt to increased loads, and aims to increase maximal performance.
Ideal locomotor strategies have a threshold, and this can come into play when pushing beyond ones limits. When this "functional threshold" is exceeded then the athlete will use more primitive stabilising strategies and there will be joint decentration. For example when doing a pull up and exceeding the capacity of the deep stabilising system the athlete will tend to hyperextend of the spine, protract the shoulders, and antevert the pelvis.
When going past this functional capacity, the athelete falls into the "functional gap". The nature of training is pushing into this functional gap, and using DNS principles in sport requires doing "threshold training," aiming to improve the athelete's functional capacity. If on the other hand the athlete frequently trains in the functional gap, then those high threshold compensatory patterns become the norm. Atheletes can be successful by working in the functional gap, but this can increase the risk of injury and prolong recovery, and reduce their true performance potential and longevity.
The following always needs to be assessed in sport:
- Centration/decentration of joints (movement segments) and deviation from neutral alignment
- Relationship between centration of distal and peripheral joints
- Timing between the function of stepping forward and support of the extremities
- Range of motion of the upper and lower extremities during stepping forward and support functions.
Occupational Applications
The same concepts used in sport can be applied to the occupational athlete. E.g. the labourer, the assembly line operator, etc. Just like the sporting athlete needs to train for their sport, so too should the occupational athlete train for their occupation.
Clinical Examples
DNS can show success in various cases, including:
- Chronic hiccups and associated pain due to diaphragm dysfunction.
- Gastroesophageal reflux linked to poor diaphragmatic function and core stability. Restoring diaphragm function can increase gastroesophageal sphincter pressure.
- Chronic low back pain and knee pain stemming from pelvic asymmetry and poor stabilization patterns.
- Running performance issues related to chest pain/weakness originating from diaphragm/stabilization problems.
- Headaches resulting from postural strain (e.g., prolonged poor posture while reading) causing muscle tension (like sternocleidomastoid).
- Sacroiliac joint pain related to instability.
- Thoracic outlet syndrome symptoms unrelieved by surgery, responding to first rib mobilization and stabilization training.
- Neck/shoulder pain (including disc issues or rotator cuff problems) by addressing underlying postural faults, scapular instability, and restricted thoracic mobility, reducing stress on the affected structures.
- Back pain associated with prolapsed discs, improving with stabilization exercises.
Treatment often involves managing both the local pathology/segmental dysfunction and the global motor dysfunction perpetuating it. Identifying and changing causative behaviours (e.g., poor phone posture, training errors) is also important.
Conclusion
DNS assessment compares a patient's stabilization patterns against the ideal developmental kinesiology model. Treatment focuses on optimizing internal muscular forces across joints by tapping into innate locomotor patterns. This functional approach emphasizes restoring the body's programmed movement patterns, offering potential for injury risk reduction and performance enhancement. Listening to the patient, careful observation, and manual assessment are crucial alongside targeted exercises that often replicate developmental positions.
See Also
Video
Resources
References
- ā Huang, Huanjie; Xie, Haoyu; Zhang, Guifang; Xiao, Wenwu; Ge, Le; Chen, Songbin; Zeng, Yangkang; Wang, Chuhuai; Li, Hai (2024-12-26). "Effects of Dynamic Neuromuscular Stabilization Training on the Core Muscle Contractility and Standing Postural Control in Patients with Chronic Low Back Pain: A Randomized Controlled Trial". doi.org. Retrieved 2025-04-28. no-break space character in
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Also thank you to the multiple tutorials by Dr Steve Bentley.
Literature Review
Literature Review
- Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf
- Articles from all years: PubMed search, Google Scholar search.
- TRIP Database: clinical publications about evidence-based medicine.
- Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,
