Peter Attia MD#152 - Michael Rintala, D.C.: Principles of Dynamic Neuromuscular Stabilization (DNS)
EVERY SPOKEN WORD
70 min read · 14,218 words- 0:00 – 3:15
Intro
- PAPeter Attia
[upbeat music] Hey, everyone. Welcome to the "Drive" podcast. I'm your host, Peter Attia. Hey, Michael. Thanks for, uh, coming all the way out to Austin to, uh, work on some DNS for a few days with me and Beth.
- MRMichael Rintala
[lips smack] Uh, thanks for having me. Thank you.
- PAPeter Attia
Um, been wanting to sit down for quite a while. Um, and obviously the events of 2020 kinda got in the way of that. But, um, m- m- maybe just start for folks by, uh, giving a little bit of your background. You grew up in Northern California, right?
- MRMichael Rintala
Yeah, grew up in Northern California, and, uh, eventually went to school down in San Diego at UC San Diego. Um-
- PAPeter Attia
What sports did you play growing up?
- MRMichael Rintala
Um, my primary sport, or the sport that I was most passionate about, was tennis. And, uh, interested in that from an early age, and, uh, played other sports, other organized sports, but tennis was the one that I was drawn to and had the passion for. So early on, uh, specialized in that, played, uh, lots of junior tennis tournaments, trained a lot. Eventually, um, played in college. And, um, that obsession or passion kind of drove me to the way that I practice today. Um, I'm a chiropractor. I'm based out of San Diego, California, as you know. Um, I s- kinda specialize in rehabilitation, sports medicine. Um, I am also-- So I have the private practice there. I'm fortunate enough to also be able to spend some time, um, on the PGA Tour and the World Surf League Tour as part of their, uh, sports medicine crew or team, and also fortunate enough to be part of USA Surfing Performance Committee, um, helping with, uh, assessing and training the, the, uh, US athletes, the surfing athletes for the upcoming Olympics.
- PAPeter Attia
Cool.
- MRMichael Rintala
So...
- PAPeter Attia
Um, today obviously the thing we wanna talk about is this super kinda deep dive into something called dynamic neuromuscular stabilization. Now, folks listening to this have probably heard me talk about this in the past. Uh, you know, if they follow me on social media, they'll notice from time to time I'm doing movements, um, that probably look a little silly, [lips smack] uh, sometimes working with you or working with Beth or working with another colleague of ours, Michael Stromsness. This is actually how we all met. Um, but I think for the purpose of this discussion, let's assume a person has never heard of DNS, um, 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, um, school of rehabilitation coalesced around this idea
- 3:15 – 5:00
Michael’s background in chiropractic sports medicine and rehabilitation
- PAPeter Attia
of what we call DNS? So going back to the founding fathers of the Prague School and what these various, um, sort of insights were that each of them had and, and how that sort of came together.
- MRMichael Rintala
[lips smack] Okay. So, um, DNS or dynamic neuromuscular stabilization kinda built on some pioneers of functional rehabilitation. Um, there's many, uh, that have been part of the Prague School of Rehabilitation, but I think, uh, talking about the influence on the development of dynamic neuromuscular stabilization by Professor Pavel Kolář, who runs the, the rehabilitation department at Prague School, um, uh, at this time. I think we need to go back, um, post, uh, World War II. Cold War era, 1950s, is where, um, Prague School of Rehabilitation was, was really founded, and it was, uh, founded as part of the medical faculty of Charles University in, in, um, in Prague in the Czech Republic, or formerly Czechoslovakia, now Czech Republic. And being post, uh, post-World War II, Cold War era, so they were in Eastern Europe behind the wall, um, m- that may have been a factor for their, uh, not reliance, but tendency towards the use of, of observation in both diagnostic, diagnosis, um, both observation
- 5:00 – 19:00
The Prague School of Rehabilitation, and functional rehabilitation as the foundation of the dynamic neuromuscular stabilization (DNS) program
- MRMichael Rintala
and palpation for diagnosis and treatment. Um, all three of these pioneers were neurologists. Um-
- PAPeter Attia
And, and who, who were the three?
- MRMichael Rintala
So the three, um, Vladimir Janda, uh, Karel Lewit, and Vaclav Vojta. Um, Professor Janda, um, he had a keen sense of observation, um, and he formulated, um, concepts and principles that tied into postural habi- postural habituation, um, specifically the tendency for specific musculature to tend towards tightness and other musculature to tend towards weakness. And he, he termed this, uh, upper cross and lower cross syndrome. So for example, with, uh, an upper cross syndrome, meaning the neck and shoulder region, um, with demands of, of life and the, the tendency towards postural habituation, such as with sustained seated postures. Um, there's a tendency towards, uh, the, the muscles in the back of the neck, the occipital muscles, the sternocleidomastoid muscle, which is the muscle that it also attaches to the skull and down to the, uh, sternoclavicular joint, the pec muscles, the upper traps. That musculature would tend towards a tightening or an overactivation. Other mus- musculature in the upper extremity, the serratus, which attaches to the ribs and, and the back of the, the scapula, um, the deep neck flexors, the middle and lower traps would, would have a tendency to tend towards the, a weakness. And with that, um, tendency f- towards overutilization or hypertonicity and underutilization, um, inhibition weakness, um, that would also-- he also recognized that that would affect the, um, quality of, of, of movement throughout the kinematic chain, and subsequently would lead to overload in specific areas throughout that kinematic chain. So that was, um, a big contribution on his part. Um, his colleague-
- PAPeter Attia
Where would those places of overload be? So if you, 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?
- MRMichael Rintala
Right. So you, with that imbalance and that postural, uh, tendency towards postural habituation, you would see a tendency to overload in the transitional areas throughout the spine and throughout the extremity. So, um, it didn't go into the specifics for lower cross syndrome. Lower cross syndrome, you have a tendency for the flexor, hip flexor complex to be overactive, tightened, so the psoas, iliopsoas, rectus femoris. Um, the, uh, uh, back extensor musculature will also tend towards tightness, and then the weakness or the inhibition will tend toward-- be towards the lower abdominal region and the gluteal region. So looking at it globally, um, you would see a tendency to overload again throughout the extremity, um, throughout the extremities, so the, the hip joint, the knee joint, um, 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, of the curvatures, uh, lordosis and kyphosis. And, um, uh, with that, um, tendency for overload, you will get repetitive stresses on the passive structures, uh, within that kinematic chain. So, uh, as a clinician, uh, 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, uh, pathology. And those changes aren't, uh, aren't usually, uh, traumatic. They're not an acute. They're accumulated over time. So the, the observation of these postural patterns or postural syndromes and then the recognition of the, um, dysfunction, uh, with, with movement efficiency that it caused led him to develop specific treatments, um, uh, both, uh, exercise-wise and manual-wise to ad- to address those, those issues. Um, his colleague, Carl Leavitt-
- PAPeter Attia
No, but Jan, Janda also had suffered polio as a, as a, as a youngster, didn't he?
- MRMichael Rintala
Yeah. So he, he had the, suffered the residual effects, the post-polio type syndrome, and that was probably a, a motivation for his, his passion for rehabilitation, his, his passion for the observation of, of movement. Um, uh, his, his, uh, colleague, Carl Leavitt, also a neurologist, um, he shared that, that observation palpation, um, uh, not technique, but, uh, tendency to utilize that for diagnosis and, and treatment. He, he specifically focused on joint dysfunction, soft tissue dysfunction as it related to those, those upper and lower cross syndromes. So he developed specific mobilization techniques for both the, the joint and the soft tissues, um, a- addressing what they were seeing with those, those postural, uh, postural habituation and movement dysfunction. Um, the third kinda pioneer, also a neurologist, uh, but also a pediatric neurologist, was Vaclav Vojta. And he, uh, his, his observations observing the ontogenesis or the, the development of motor function after birth during the first twelve months where the postural, uh, or postural foundations are established neurologically. Um, he developed, uh, specific, uh, tests called postural reactions where he could, uh- tell the, 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, um, or a healthy developing central nervous system. So he, he developed s- uh, seven specific postural, uh, reaction tests, developed and modified some other ones, utilized, uh, primitive reflexes and, uh, just observation, observation of the infant during development to be able to recognize the biological age, meaning the, 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. He f- his focus was on, uh, treatment of the cerebral palsy infant and, and patient, and he was able to utilize that observation, those, uh, uh, the observation of the postural reactions, the assessment of the primitive reflexes to, um, 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, the brain to form motor engrams, um, uh, more efficiently and work around those central lesions that you see with cerebral palsy. So he, um... all three of these, uh, f- kind of founding, um, members or founders of Prague School of Rehabilitation were, are Professor Kolář, Kolář's, uh, colleagues, mentors, instructors. They shared patients, they discussed cases, and, um, uh, Pavel Kolář developed or evolved all that, that knowledge and experience into what we call dynamic neuromuscular stabilization today.
- PAPeter Attia
Now, before, um, Pavel came along, what was the-- So, so fast-forward, this started in the '50s, but fast-forward to the '90s. Uh, 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, how, what was the breadth of the eco- um, applicability of the Prague School?
- MRMichael Rintala
Right. So, uh, Prague School, uh, was, it's a group of clinicians and, um, probably more the, the early '90s, the application was primarily rehabilitation, uh, cerebral palsy, general population. Um, uh, with, uh, Pavel, uh, Professor Kolář, just to go in a little bit of his background, um, you know, again, he, he's the head of Prague School of Rehabilitation. He's also head clinician, uh, for the Czech Olympic teams and Czech national sports teams, hockey, soccer, men's and women's tennis. He himself was a high level, uh, uh, like Olympic level gymnast. So, um, he, uh, his, his work, he's a pediatric, uh, physiotherapist as well. Um, his work with those three pioneers, uh, his experience as an athlete, his experience treating cerebral palsy and, and infants, um, he took that or started to apply that base of knowledge to the athletic population. And the, the focus of, of, and the, the thinking of these, these founders of Prague School and, and Prague School today is it's, uh, the, the influence of the central nervous system is huge and kinda king as far as the, uh, facilitating the efficiency of transfer of load throughout that kinematic chain. So early on, the focus was more rehabilitation, um, over multiple populations. But maybe late '90s, um, early 2000s, Pavel started to, uh, apply those teachings to that athletic population. And, um, you know, there's-
- PAPeter Attia
Meaning to an uninjured athletic population or to an injured athletic population?
- MRMichael Rintala
Probably at that time, more of an injured population. Um, two kinda stown- standout a-athletes that he was able to work with and integrate his concepts and principles of dynamic stability were, uh, J- Jan Železný. Hopefully I say that right. He's a, he was a, uh, Olympic, uh, javelin thrower, three-time gold medal winner, still holds the, the record for, uh- Uh, javelin, uh, 98.48 meters, I believe. And, um, the other one is Jaromir Jagr, who, uh, hockey player, Czech hockey player. [lips smack] Um, he, uh, he was able to, uh, help and work with them, uh, help them rehabilitate from injuries, but then also integrate the concepts and principles of dynamic neuromuscular stabilization to, one, uh, decrease the risk of re-injury, but two, also provide the potential for better performance.
- 19:00 – 28:15
Foundational principles of DNS, and the role of the diaphragm in muscular stability
- MRMichael Rintala
And we can talk about specifics of those concepts and principles.
- PAPeter Attia
Yeah. Let's, let's... So, so we're, we're into the early 2000s where now Pavel's basically taking [clears throat] s- some of the, the, the fundamental principles from the Prague School and creating this, this new discipline. Let's use each of the words to explain to people what this is. So dynamic, of course, is movement.
- MRMichael Rintala
Mm-hmm.
- PAPeter Attia
Right? It's not just static. It applies to in, in motion. Um, neuromuscular, um, 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. Uh, for me personally, the hardest one to explain to an unsuspecting audience is stabilization.
- MRMichael Rintala
Mm-hmm.
- PAPeter Attia
Now, I have a way that I like to explain it, but I, I wanna hear you go first.
- MRMichael Rintala
Okay. [clears throat] So I think it, it, it's important to, uh, talk about the utilization of developmental kinesiology, um, as a way to explain posture and explain dynamic stabilization. Um, 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, uh, the, the lower central nervous system structures, the brainstem level is kind of dominant, so primitive reflexes are dominant. Um, but there's-
- PAPeter Attia
So examples of that, suck reflex-
- MRMichael Rintala
Sucking reflex
- PAPeter Attia
... gag reflex-
- MRMichael Rintala
Grasping reflex
- PAPeter Attia
... grasping.
- MRMichael Rintala
Yeah.
- PAPeter Attia
You know, obviously being able to blink. I mean, the most primitive reflexes that our species... I mean, we take these for granted.
- MRMichael Rintala
Mm-hmm. So they help keep us alive during that, that period of time. So as that central nervous system matures, and if it's maturing in a healthy way, by a three-month period of time... Actually, let me go back. Usually starting maybe eight weeks, you, we start to facilitate the, the synergy, coordination, and timing of the deep stabilizing group of, of musculature, and that's diaphragm, pelvic floor, the entire abdominal wall, the intersegmental spinal musculature that runs throughout the entire spine.
- PAPeter Attia
All right, I'm gonna stop you right here. We are gonna talk about these things so much that I wanna make sure people understand them.
- MRMichael Rintala
Okay.
- PAPeter Attia
So let's go back to the first one. Everybody's heard of their diaphragm.
- MRMichael Rintala
Mm-hmm.
- PAPeter Attia
But let's put some actual, um, metrics to it. It's a dome-shaped muscle. It's a striated muscle.
- MRMichael Rintala
Mm-hmm.
- PAPeter Attia
But it has kind of a, a, a non-muscular part as well. But I think what most people don't appreciate is how big it is, right?
- MRMichael Rintala
Mm-hmm. Yeah.
- PAPeter Attia
And how... I, I can't even remember. It's been s- You know, back when I was, you know, in school I had to know every attachment of it.
- MRMichael Rintala
Right.
- PAPeter Attia
But it, um... Do, do you recall how far it attaches down and up on the, on both the, the ribs and the vertebral bodies?
- MRMichael Rintala
Yeah. So the diaphragm, just think of it like a big parachute or a big sheath of, of muscle that separates the abdominal cavity from the, the heart and lungs. The attachments, it has attachments on the lower six ribs, on the, uh, back of the xiphoid process, which is a little bone at the end of the sternum, and then also attachments on, uh, L1, L2, uh, vertebra.
- PAPeter Attia
That's amazing.
- MRMichael Rintala
So right around the, the thoracic lumbar junction.
- PAPeter Attia
Yeah.
- 28:15 – 32:30
Types of muscle contractions
- MRMichael Rintala
or like I, you know, describe it 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, uh, an, 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.
- PAPeter Attia
Let's again make sure people know exactly what we mean, 'cause we're gonna use the terms a lot. When you talk about eccentrically versus concentrically loading, um [clears throat] I mean, 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.
- MRMichael Rintala
Yes.
- PAPeter Attia
Eccentrically is getting longer as it's being loaded. So, uh, for example, a bicep curl, this is the concentric phase of loading.
- MRMichael Rintala
Yes.
- PAPeter Attia
This is the eccentric phase of loading.
- MRMichael Rintala
Yes. Yes.
- PAPeter Attia
And I think what's-- what a lot of people take for granted is both of those are important.
- MRMichael Rintala
Yeah.
- PAPeter Attia
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 [clears throat] when a group of U.S. 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 one is up and down. So it was they were putting all their effort into the concentric, but then, you know, 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 l-lifters were doing the opposite, right? They were counting it as two reps. A r- it's up One down, two. So it was just as much effort into that eccentric.
- MRMichael Rintala
Right.
- PAPeter Attia
Um, and y- you know, it, it's not to say one is right or the, or, or, or wrong 'cause they serve different purposes. Obviously, more emphasis on the eccentric will create more hypertrophy. Um, so, so there are times that you want both. But, um, a- again, when you look at, for example, and we'll get to this, I'm sure, but when you look at, um, 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.
- MRMichael Rintala
Yeah. Yeah. So what the, 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, um, providing that fixed point, and then allowing efficient transfer of force and load throughout that, that trunk and pelvis area. Um, what, uh, these pioneers, um, Vojta, Janda, Levitt, uh, Kolaj, uh, noticed was the importance of the quality, basically training that central nervous system. Because if you can facilitate that ideal stabilization, uh, stereotype and, and synergy, then you provide, um, what, uh, Professor Kolaj calls centration throughout that, that chain of movement, throughout that kinematic chain. And w- what he describes centration as is, uh, for example, let's say you have the hip joint. Um, is the ability to maintain an ideal position
- 32:30 – 50:00
Human motor development through the lens of DNS, and when issues begin to arise
- MRMichael Rintala
of the, 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, the biceps curl. So an interplay between, um, 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 gonna affect the, the quality of centration or transfer of force and load, um, above and below that region. The quality of, uh, that synergy coordination timing of that deep stabilization is what Prague School is focusing on with assessment and with their, their treatment methods. And [clears throat] this is based out of that observation of developmental kinesiology, which is the neurophysiological aspects of the maturing locomotor system. So that's their-- They utilize that as their definition of dynamic movement, dynamic posture, ideal s- uh, ideal posture.
- PAPeter Attia
Let's go back to [clears throat] the, the three-month-old infant and start talking about what normal developmental milestones are through the lens of DNS and, um, like picking it up at three months. So, um, what is, 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?
- MRMichael Rintala
Right. So, uh, at three months, with that ability to create that fixed point, uh, now the larger, uh, longer musculature, uh, and larger, uh, 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, you know, there's the ability to, to, to fix their, their gaze is not there. By three months, providing that, that stable point, now they can turn, fix their gaze, and 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, to start to explore. Um, the infant at that period of time can lift the, 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, their hands together and bring their hands to their, to their mouth. Along-
- PAPeter Attia
And, 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, that is being hardwired in that three-month-old infant that is pretty impressive and, and when you really stop to think about it, that they're able to bring both legs up, um, coordinate that movement? And by the way, are they necessarily doing that the way, you know, uh, a, a 50-year-old person would do that if you laid them on their back? Like I-- 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.
- MRMichael Rintala
Right. So, um, neurologically, the s- the coordination and timing of that deep stabilization, uh, group of musculature needs to be on point to be able to create an, uh- fixed point so that the, again, the, the larger muscle groups can anchor off that to, to bring the legs up. Now, the infant has different, 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 mu- the, the bones are still forming. So that's much different than a 50-year-old. Our propor- our limb proportions are different. Our mobility is gonna be different. We may have different, um, body proportions, you know, mobility, but we, we all went through these developmental milestones, and, uh, most of us develop, uh, our central nervous system in a, a healthy way, so we still have those same motor patterns that our central nervous system's gonna wanna kick into. Um, some of the, uh, efficiency of accessing those nice stereotypical motor patterns that we're born with can be compromised due to, uh, soft tissue dysfunction, rigidity, lack of range of motion throughout the, throughout our joints, um, you know, postural h- habituation that, that Yanda described. Um, all that factors into our, our... can override the access to those ideal patterns. Um, what Prague School tries to do is with the specific assessments, as- assess that efficiency of that deep stabilization system, uh, 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, we'll get back to in a second, um, to utilize specific points of support and positioning to help wake up or facilitate those patterns that we, we still have as adults. So, uh, three months of age is the start of that ability to, to create a sagittal stabilization.
- PAPeter Attia
Tell people what sagittal means versus coronal.
- MRMichael Rintala
Um, so sagittal is kind of like straight ahead.
- PAPeter Attia
Sure.
- MRMichael Rintala
Uh, frontal plane would be if you're on your side, uh, or to, to the side, and then there's transverse plane, which is, uh, think about rotating, uh, in the, the transverse plane. So-
- PAPeter Attia
So what happens now as they approach six months of age?
- MRMichael Rintala
So three months, you see the start. Four months, that coordination is usually complete. Four, four, four and a half months, once you've, you've, they've completed that, that ideal, uh, facilitation of a fixed point, now they start to be able to utilize the oblique slings, and you'll start to see some differentiation, uh, in the pelvis and, and the limbs. And, um, [lips smack] uh, as that, uh, 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, the infant's, uh, range of, of reach will, 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. [lips smack] And then by seven months, they're bringing the foot to the, to the mouth. The, uh, there's enough synergy-
- PAPeter Attia
And, 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 are quite flexible at birth.
- MRMichael Rintala
Right.
- PAPeter Attia
It's, it's more that they now have the motor control and the stability to coordinate something that is everywhere from shoulder to foot-
- MRMichael Rintala
Right
- PAPeter Attia
... or hand to foot, basically.
- MRMichael Rintala
Right. And do it in, in, in a, an efficient manner. So, uh, you know, I'm a parent. You're a parent. And you remember when the, when the kids were developing, and I, I, I get this all the time. They're like, "Oh, my son was rolling all the way over at three months." Um, th- that is possible. They can, uh, 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 gonna do it with that coordination and that efficiency of transfer of force and load. You may see them turn and kinda revert back to more of the, the newborn posture, meaning, uh, they're finding a way to turn. They're using more of a compensatory pattern to make that action happen. Kinda the same thing you see with movement w- with adults. Uh, if the, the synergy, coordination, timing of deep stabilization is, is not on point, they find a way to move. But when they move, as with, uh, the first weeks of life, the, the newborn infant, you'll see, uh, anterior pelvic tilt. You see a flaring of the rib cage. The shoulders, you'll see elevation, protraction, and recline or extension through the cervical spine. The newborn, when they look or when they move, the whole body is, is moving. They don't have that ability to create that fixed point. But they're still able to, uh, to make movements as they're going through the developmental milestones, uh, with that motivation or that drive to move and explore their environment. They may find ways to, you know, reach that toy but not be creating the ideal centration and stabilization. Um, 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, there's thousands of trials and errors. They're forming the brain mapping and motor engrams, finding the right points of support as the, the coordination of the central nervous system is kicking in. So you may see, uh, at the beginning of, of six months and they're turning, you know, maybe they're not able to, uh, keep the alignment of the diaphragms during the, the turning, but they're still able to do it. Maybe by then s- uh, s- 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, of activation.
- PAPeter Attia
[lips smack] So how does it go from there? What gets them to crawling and ultimately standing?
- MRMichael Rintala
Right. So what you see with the developmental milestones, um, the start of at three months, uh, we talked about with the newborn, you have more of the lower, uh, 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, uh, postural foundations. So as that central nervous system matures, the m- certain milestones, three months, four months, five, six, seven, you'll see the infant starting to be able to attain higher, more unstable positions. And this, this, these developmental milestones are moving towards basically the verticalization process, going from either supine on the back or prone, and then, uh, working their way up, trial and error, uh, learning with that healthy central nervous system maturation, where, uh, at seven months, they're able to come to their side. Uh, eight months, they come up into what we call, uh, the high oblique sit position. Nine months, they're able to crawl. Um, uh, 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, you know, on average, you see the start of, of ambulation. Now, this is, is variable. Some kids, my son was walking at 10 months. Others, maybe 15 months, 16 months. So there's variability within, uh, these milestones of, of where, where we see the, the infants. But on average, these specific points, you'll see a specific, uh, uh, competency in stability and, uh, reaching or moving towards that verticalization process.
- PAPeter Attia
Now, if you exclude, um, you know, 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, um, is it more or less the case that, you know, all kids are-- who are, you know, given the fair chance to sort of explore and go about these things naturally will reach a certain age, call it two or three, um, and they'll be quite healthy from a, from a dynamic, uh, you know, and movement standpoint? Like, is it... You know, for example, like yesterday, we spent a bunch of time looking at my three-and-a-half-year-old, and, uh, you know, it's, it-- frankly, it's a clinic in movement at that age, right? Um, is it safe to assume basically all three-year-olds move really, really well? Like, they haven't, uh, started to get into the habituated, uh, movement patterns that will begin to destroy them, right?
- MRMichael Rintala
Yeah. So, uh, Vojta and, and others talk about usually what they see is around 70% of new, you know, infants are going to have that healthy central nervous system maturation, uh, go through the first weeks of life, the postural foundations, the, the three to 12 months, the subcortical. And then from two, four to six, six years of age, you have more of the cortical maturation, where you see fine motor dexterity and movement, you know, ability to, to write, and you see the, uh, language develop, and you see motor learning. Um, uh, so-
- PAPeter Attia
And so sorry, the subcortical phase goes till about two?
- MRMichael Rintala
Um, three, yeah, three, three to 12 months is where we see these-
- PAPeter Attia
Okay
- MRMichael Rintala
... the postural foundations. Uh, after that, you start to get that cortical integration-
- PAPeter Attia
Got it
- MRMichael Rintala
... maturation. But the, the, um, the motor learning and, and the, the process-
- PAPeter Attia
Yeah, they obviously overlap
- MRMichael Rintala
I mean, it's like two to six-
- PAPeter Attia
Yeah, yeah
- 50:00 – 56:45
Common postural syndromes
- MRMichael Rintala
not, uh, as efficient, um, movement patterns. And this is something that, uh, Prague School, as far as a curriculum, um, there's a whole pediatrics section dur- with their curriculum, which they go deeper into that aspect of observation and, uh, specific utilization of, of treatment options. So, um, so it usually y- with a h- a healthy central nervous system maturation and a good environment for the child to explore movement and the variability of movement and do the, the trial and, and error and find their ideal points of support, you're gonna see this nice, healthy maturation. Things that may compromise that, I mean, we see in, in m- modern society and culture, the kids who, a kid who's in their car seat, you know, six hours a day or, um, [lips smack] is maybe doesn't have that environment where they can explore, um, and, and crawl.
- PAPeter Attia
I, I think another one that I remember Michael sharing with me was when kids are sped up on milestones. So for example-
- MRMichael Rintala
Right
- PAPeter Attia
... you know, those, those seats that prematurely prop kids into a seated position.
- MRMichael Rintala
Jumpies. Yeah.
- PAPeter Attia
Well, even before that.
- MRMichael Rintala
Or the, yeah, yeah, yeah.
- PAPeter Attia
You know, that little Bobby chair?
- MRMichael Rintala
Yeah.
- PAPeter Attia
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, 'cause when our third kid came along, I was already interested in DNS, so then he became-
- MRMichael Rintala
[chuckles] Right
- PAPeter Attia
... sort of, uh, you know, the observation for DNS. But with our first two, y- yeah, you're gonna stick them in those silly seated chairs, and they're, you c- they don't have the support.
- MRMichael Rintala
Before they're ready.
- PAPeter Attia
Before they're ready.
- MRMichael Rintala
Yeah.
- PAPeter Attia
So they can't even support their own weight, so they're in this slouched position. And then you put them in those things. We called it the circle of neglect. So it's like the thing where, you know, they're standing before they should be standing.
- MRMichael Rintala
Yes. Yeah.
- PAPeter Attia
Um, so all of these things actually interfere with the normal, uh, neuromuscular development.
- MRMichael Rintala
Yeah. Yeah.
- PAPeter Attia
Putting, p- putting kids in shoes too early-
- MRMichael Rintala
Yes
- PAPeter Attia
... probably does a tremendous disservice to them.
- MRMichael Rintala
Right. So i- ideally, they're gonna have an environment where they're gonna f- kind of figure this out themselves verse, you know, the, another one is the little walkers that they'll hold onto and, and walk. Um, you know, ideally, they're going to play with their environment and, uh, with that combination of healthy central nervous system maturation, find those ideal points of support, and be able to, uh, utilize that, those m- motor patterns that are manifested with that healthy central nervous system. So, uh, the environment that we, we have children in is key. [lips smack] And, um, this, I mean, you can take this, uh, and look at, you know, just our society just with, uh, as adults.
- PAPeter Attia
Well, yeah.
- MRMichael Rintala
Yeah.
- PAPeter Attia
Let's, let's-
- MRMichael Rintala
Yeah
- PAPeter Attia
... let's go from, okay, so w- we, we, we can put them in shoes too early, put them in silly sit-up s- seats in the circle of neglect, and give them walkers. And then another huge set of insults come when they go to school, right?
- MRMichael Rintala
Yes.
- PAPeter Attia
Because now they're sitting in chairs-
- 56:45 – 1:03:45
Increasing functional threshold to minimize time in the functional gap
- PAPeter Attia
you see it when he breathes. It's his, it's abdominal expansion more than it is thoracic expansion.
- MRMichael Rintala
Right.
- PAPeter Attia
These, you know, a, a child that age, if doing thing, you know, if, if developing normally, is not using any of these accessory respiratory muscles.
- MRMichael Rintala
Yeah.
- PAPeter Attia
Um, and there's something about this anchor point being in the abdomen, right? I mean, one of, one of the first things I learned in DNS was how to regain intra-abdominal pressure-
- MRMichael Rintala
Mm-hmm, yeah
- PAPeter Attia
... through eccentric loading of that cylinder. And I, I, I don't think it had ever been presented to me how important that was, because prior to that, any amount of, uh, perceived intra-abdominal pressure had been acquired through concentric loading.
- MRMichael Rintala
Right.
- PAPeter Attia
So for example, when trying to pick up something heavy, you can, you can take two strategies to that. I think, I think most people would agree, if you wanted to pick up 300 pounds right now, you must generate pressure in the abdomen. I don't, I don't think anybody would assume that you could pick up 300 pounds, which is twice your body weight, without generating pressure here.
- MRMichael Rintala
Mm-hmm.
- PAPeter Attia
But how you do it matters.
- MRMichael Rintala
Right.
- PAPeter Attia
So e- explain those differences. And, and again, e- either with or without the developmental lens, but I, but I, I think that, um, the developmental lens is always a great way to think about how kids move.
- MRMichael Rintala
Right. So, uh, if you think about developmentally and how that stabilizing stereotype, uh, evolves, think of it as a, 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, uh, for whatever task that you need to, to do. So if I'm sitting here and I'm gonna pick up that pen, I don't... I need some, uh, function of stabilization to then, you know, move this limb, try to f- 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, a certain amount of management, uh, of that intra-abdominal pressure that I need. If I go to, like, the chairs that we're sitting in that we, we, [chuckles] we moved earlier, this is a lot more weight. I'm gonna 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, you know, my arms holding, holding the chair. So there's, uh, more facilitation of that intra-abdominal pressure. Um, so that's what we see developmentally, um, that quality of, of stabilization. And that stabilization, it's not static. It's, it's, it's dynamic. We should be able to manage that intra-abdominal pressure through full extension, full rotation, full flexion. That's the, the, the beauty of that dynamic neuromuscular s- stability, and that's what we see with our, that quality we see in the high, high-level athletes. The... We can also create stability by bracing. And if you think about bracing, if someone's gonna punch me in the stomach, I may go for a, a concentric. And where the, the abdominal wall shortens and tightens, I'm still creating a, uh, a stabilizing function, and I can still use that to, you know, move objects or prefer, prepare for, for impact. When it comes to dynamic movement, the, the, uh, inside-out strategy and the central nervous system management of that stabilization, uh, allows me to create the stability efficiently where I need it, but then also be able to, for example, relax, uh, my extremity. So with- 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 Fedders, the Kelly Slaters in 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 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
- 1:03:45 – 1:10:00
DNS for injuries, pain, pre-habilitation, and performance enhancement
- MRMichael Rintala
patterns, it's not all the time.
- PAPeter Attia
Well, 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.
- MRMichael Rintala
Right.
- PAPeter Attia
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.
- MRMichael Rintala
Yes. So when I lecture, I use Federer as an example. You know, you look at his career, just longevity and injury-wise. You know, he has been injured, but usually you see a quick recovery. Going back to Jager and Zelezny, Zelezny had a 20-year career in javelin, which I don't think is very common. Jager is 48. He's still playing. With Jager and Zelezny, 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 it differentiate, you know, within, for example, the pelvis over that femoral head. So the focus with them was the quality over quantity, I guess you can say.
- PAPeter Attia
Like what percentage of his time do you think, because obviously Federer has just an unbelievable functional capacity.
- MRMichael Rintala
Right.
- PAPeter Attia
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?
- MRMichael Rintala
So I think when you see those athletes that rise to the top, they have that. You watch Federer, for example. You see the creating the point of support, the positioning, the alignment of everything. He's creating naturally that centration and that transfer of 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 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 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, then And on top of that, you have amazing, you know, potty awareness and cortical function, you're gonna see longevity, and you're gonna see nice quality of, of movement. What I see on the other end is players, athletes, poor training programs, over-training, you know, spending too much time in the, the functional gap, um, you know, falling into what my colleague Rich, Rich Olm talks about, the extensor compression syndrome, which you see a lot with lifting with the, the power athletes, uh, which he works with a, a lot of. Um, then you see when you have that reliance on that higher threshold, you see more incidents of injury, longer recovery, versus the opposite, the, the Federers. Um, yeah, they get injured, but they recover fairly quickly, and that's what you see. Again, Jagr and, and Železný are nice examples of that, both Czechs, and Pavel working with them, you know, over this 20-year period of time, integrating and putting in his ideas and his, um, [lips smack] experience with everything that we talked about with those, you know, rehabilitation pioneers into these athletes, um, kind of like a l- you know, test subject, so to speak. So now you, uh, Prague School and DNS practitioners, that's what we're trying to help integrate, um, with our athletes, with the general population.
- PAPeter Attia
So what, what percentage of people that you work with are, um, coming with an injury and, 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 we're gonna... You're gonna learn how to stabilize your neck or stabilize your head using the stabilizing muscles appropriately. You're gonna learn how to generate concentric intra-abdominal pressure, and you're gonna learn how to centrate ipsilaterally and contralaterally and all of these things"? And then what percentage of your, uh, patients are not coming with an injury but are coming for performance enhancement and saying, "You know, I just can't throw this fastball any faster than 89 miles per hour,
- 1:10:00 – 1:16:00
Etiology of back pain
- PAPeter Attia
and y- 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"? You know? So those are two ends of the spectrum, and how do you spend your time on those two?
- MRMichael Rintala
Right. So a majority of people are coming to me because pain and, and injury. Uh, what happens, especially with the athletes, once we address that, once we calm down, whether it's-- if it's acute or chronic injury, we calm-- we decrease pain and, um, [lips smack] uh, and utilize the, the... There's different manual, uh, methods within DNS and then integrating the exercises that are based off of those developmental milestones. Once they get to a certain point, um, [lips smack] ideally, I'm going to work with a trainer or with a coach, and hopefully they're on the same, you know, mindset so that, uh, they can then progress to the strength training, to the, the specific technique. More and more, these athletes are... You know, it's a combination of once they're out of pain, uh, we work with the quality of stabilization and movement and transfer of force and load. Um, the o- the-
- PAPeter Attia
Let, 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, what, what, of that 100 will stay with the program to get better?
- MRMichael Rintala
Right. Not enough.
- PAPeter Attia
So what's the number?
- MRMichael Rintala
So, um, 10, 20% maybe.
- PAPeter Attia
That's it?
- MRMichael Rintala
Yeah. What I see happening, you know, for example, uh, Major League Baseball is integrating DNS more and more. So, um, in San Diego with the Padres, I've started to consult with them a bit. Um, there's, um, a hitting coach, uh, for the Dodgers that comes in, and we kind of workshop ideas, uh, where, you know, he's integrating the DNS concepts and principles. So it's starting to get recognized more for that value as far as, uh, the performance enhancement aspects of it. [lips smack] Culturally, within sport, what I see, um, especially in the West, there's, you know, they want numbers. They want, okay, what's their p- what's their lift? You know, what's their, their strength capacity? Which is important, but I think it's also important to, uh, again, like integrate those two, the quality of movement and stability, and then, uh, increasing that, you know, their, their strength thresholds.
- PAPeter Attia
But even just with an injury, so if you j- let's just say 100 athletes that are, you know, 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? Uh, uh, 80 of them would abandon the program before they improved?
- MRMichael Rintala
Um, a lot of times and, and just across the patient population, a lot of times once, once people are out of pain It's kinda out of sight, out of mind. They go back. They go back into their, their patterns. You know?
- PAPeter Attia
Oh, so wait. That, that's what I'm trying to differentiate.
- MRMichael Rintala
Yeah.
- PAPeter Attia
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?
- MRMichael Rintala
Um, so going back to that, one of my goals, especially with the athlete, once they're out of pain, we develop a, uh, prehabilitation kind of program, and we utilize those, again, the, going back to the knowledge of developmental kinesiology and developmental milestones, which, uh, w- later we'll, we'll actually go through. So based on what I'm seeing with their insufficiencies and with, with the insufficiency of that coordination of stabilization, I will give them certain things, certain sequences of movements and exercises that they practice, uh, with awareness to facilitate better strategy for stability, and then that's part of their movement preparation or prehabilitation before whether it's their strength training or their technique training or going out and, and performing. And, um, so that's, that's a larger percentage because that's part of what I kind of program into the, the rehabilitation. Um, [lips smack] so some athletes will get that, and they're, "Okay, great. This is, this is good. I'm gonna go do it." And then occasionally they're coming back and getting, [lips smack] uh, maybe we're adding to it based on what, how they're functioning now. Um, other athletes, they want more, and that's that, that's that smaller percentage. Part of it too, probably access, you know, and availability, um, uh, as far as being able to be i- you know, in San Diego and working one-on-one with me. So, um, you know, there's, there's different
- 1:16:00 – 1:20:45
How a stress fracture in his back led Michael to the Prague School
- MRMichael Rintala
factors that will, um, 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 in- integrate into their programs.
- PAPeter Attia
[lips smack] What is the most common chief complaint of a person that walks into your office? Uh, is it lower back pain? That would be my guess.
- MRMichael Rintala
Yeah. M- majority is low back.
- PAPeter Attia
Okay.
- MRMichael Rintala
Yeah.
- PAPeter Attia
So what are the most common causes of lower back pain that you see?
- MRMichael Rintala
[lips smack] Um, across the board, if, if they're suffering from, uh, you know, low back pain, uh, whether it's acute or chronic, usually there's an underlying pattern of that, uh, lack of or the inefficient activation of the, the deep stabilizing system and more of a tendency towards that extension compression, you know, um, activation, that overactivation of flexor extensor. So, you know, you-
- PAPeter Attia
Explain what that means in a bit more detail given the ubiquity of this injury-
- MRMichael Rintala
Right
- PAPeter Attia
... and the probability that, uh, 80% of the people listening to this have already experienced-
- MRMichael Rintala
Have had back pain
- PAPeter Attia
... back pain or-
- MRMichael Rintala
Right
- PAPeter Attia
... will experience back pain in their lives. I wanna make sure if people take nothing away from this podcast, they understand the etiology of lower back pain.
- MRMichael Rintala
Yeah. [lips smack] So unless you've had a, let's say a car accident or a, a fall, that's like an acute injury, um, that can be a cause of, of low back pain. The majority that I see, it's more of a, uh, chronic overload over time that, uh, if we have that strategy of, of flex, too much flexor extensor activity, which compromises the positioning of the intersegmental, the, the joints and the transfer of force and load, then with the compen- compensatory pattern, we'll see more of a hinging in through that lumbar sacral region. And with that hinging, over time, you know, it's like if you keep bending a spoon, you know, it's gonna, it's gonna break. You weaken the, uh, the structure. So, you know, uh, take a disc pro-
- PAPeter Attia
But yeah.
- MRMichael Rintala
You know? Yeah.
- PAPeter Attia
Let's, let's, let's talk about the actual anatomy, and I, yesterday I said I wished I'd brought a skeleton. So the, the sacrum is, uh, is basically a single bone. It's actually fused, so it did, at, at one point it was multiple bones, but-
- MRMichael Rintala
Right. Sacrum at the ilium. Yeah.
- PAPeter Attia
Right. So, 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, um, vertebral bodies is a disc.
- MRMichael Rintala
Mm-hmm.
- PAPeter Attia
Um, and then there's one between the, uh, fifth lumbar vertebral body and the, uh, sacrum. So, uh, we refer to them as, you know, L3, L4 is the disc between three and four.
- MRMichael Rintala
Mm-hmm.
- PAPeter Attia
And L5, S1 is the disc between there.
- MRMichael Rintala
Right.
- PAPeter Attia
Um, behind each of these vertebral bodies, so these, these vertebral bodies are sort of held in place, um, by the discs, but then also by the facet joints-
- MRMichael Rintala
Yes
- PAPeter Attia
... that run behind them, and it's really difficult to show this. We'll probably have to pull up some images-
- MRMichael Rintala
Mm
- PAPeter Attia
... uh, to make this easier for people to see. Um, but the, the facet joints and the, and then sort of the lamina, which are these, those sort of longer bones, hold it all together, but they don't really provide the support. I think the support is probably at the facet joints and at the disc interface. Is that probably fair?
- 1:20:45 – 1:44:55
The Prague School curriculum: 3 tracks for certification in DNS
- MRMichael Rintala
Both of those, with those attachments, they also come up and they attach right where the diaphragm attaches, the crura of the diaphragm. So 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. And with
- PAPeter Attia
So exaggerate what the extension posture looks like so people can see it.
- MRMichael Rintala
So your hips will move forward.
- PAPeter Attia
So if you picture your pelvis as a bowl, you're tipping the bowl forward.
- MRMichael Rintala
Tipping the bowl forward. And then if you think of your ribcage, your ribcage is coming forward as well.
- PAPeter Attia
So your spine, which normally has a bend in it, gets more of a bend in it.
- MRMichael Rintala
Excessive, yeah. And with that oblique position of the diaphragm and the pelvic floor, now there's a mechanical disadvantage of the abdominal wall.
- PAPeter Attia
So we took a cylinder that's supposed to sit like this and we made it go like this.
- MRMichael Rintala
And we put it like that. So now the tendency is going to be the extensor overactivity 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 protective spasm. Also, so 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 or 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 hour upon hour, but at a certain point, structure overload 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 orthopedist, physical therapist, chiropractic, all of them helped in their own way, but I was missing, 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 You know, in medical school and same in 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, Janda 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 in '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 Janda had passed away. I believe Vojta had passed away I think early 2000, 2001. But that was my first introduction to Professor Pavel Kolaj. And at 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 was 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.
- PAPeter Attia
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?
- MRMichael Rintala
Yeah.
- PAPeter Attia
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? Like what are the-
- MRMichael Rintala
Yeah.
- PAPeter Attia
Yeah.
- MRMichael Rintala
So there's 3 tracks of the dynamic neuromuscular stabilization curriculum. One is a clinical track. It's a 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 therapists. 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 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, they don't want DNS to be a, this is a DNS technique. These are concepts and principles that Professor Kolaj 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 and mobilization 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.
- PAPeter Attia
And so, I mean, 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.
- MRMichael Rintala
Mm-hmm.
- PAPeter Attia
Um, and frankly, even showing it is challenging. I think experiencing it is, uh, is the gold standard.
- MRMichael Rintala
That's the, that's the ultimate. Um, it's not just movement, it's not just specific exercises, but it's facilitating the awareness of the, um, the ideal stabilization and the, the support. Um, and then with that, you know, with, with my patients or whether it's training, um, I want my patients or my athletes to feel the, that synergy and feel that, uh, ability to stabilize where they need to, but then also relax where they need to. And it's a, there's a little bit of a process. It's not a, a cookie cutter thing like just do this, this, this. Um, you have to put some work into it. You have to practice it both as a patient and as a, a clinician or, or trainer. And I guess that would be, you know, maybe, uh, one of the drawbacks for people is, um, you know, everything out there people are doing, doing good work and, and trying to help people. Um, and if, you know, they have something that's working for them and we introduce these concepts and principles and they're not easily integrated, then, um, maybe they don't, they don't adapt them, or they'll a- adapt a portion of them, which is, you know, fine as well. Um, but it's, it's something that, uh, in the curriculum, uh, you know, we try to emphasize the, the need for, um, you know, uh, feeling and, and practicing the, the movements that we can show later.
- PAPeter Attia
I mean, I can only speak for myself, um, but I wonder if [clears throat] my generalization is correct. I, 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 tinkle-- 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, um, [clears throat] it, A, you don't... It, it, it, it feels a lot of the time like you're not doing much, you know?
- MRMichael Rintala
Mm-hmm.
- PAPeter Attia
And I think for someone who's used to, you know, being quite impatient with what they, you know, I want results today, and, you know, "Hey, I just started CrossFit, and two days later I'm doing power cleans. Like, this is awesome." Um, and, and if, if that's the, if that's the dopamine surge that a person needs-
- MRMichael Rintala
Right
- PAPeter Attia
... they're gonna, I think they're gonna struggle with a system where you might spend a week, you know, daily practicing learning how to breathe again. Um, and you'll never stop practicing that, by the way. You'll never stop practicing, you know, 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, um, and can be very challenging. I mean, they're-- Most of these things I still can't even do actually, especially with weight. Um, but [clears throat] I don't know. I guess I would say I always think of, um, things in medicine through the lens of efficacy and effectiveness. So efficacy is how well does something work if it's adhered to correctly.
- MRMichael Rintala
Mm-hmm.
- PAPeter Attia
Effectiveness is if you just throw it out in the real world, how well does it work?
- MRMichael Rintala
Right.
- PAPeter Attia
To me, DNS might be the single most efficacious thing I have ever come across as far as, you know, 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 gonna do it. You know, especially once you get them out of pain, they're not gonna wanna stay with it. Now, I don't know why that is, um, 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.
- MRMichael Rintala
Right.
- PAPeter Attia
It's almost impossible not to fix back pain, neck pain, shoulder pain. Like, all of these injuries, they're, they're gonna get better. Where, where we wanna do it is make sure that, hey, peop-- you know, we want 90% of people to be able to stick to it once they start.
Episode duration: 1:44:55
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