Selective Functional Movement Assessment

Katie Deaton, BS, CSCS, SPT

Goals

Disclaimer No way to provide a comprehensive course on the SFMA

and its implementation

Objectives Introduce the concept of assessing patients from a

global, movement quality perspective Present the major concepts of the SFMA, top-tier

assessments, and a top-tier breakout Facilitate a basic understanding of how to utilize the

SFMA Stimulate interest and further investigation into the

SFMA and its clinical implementation

What is the SFMA?

Meant for use by clinicians to facilitate assessment of patients who experience pain with movement Differentiates the SFMA from the Functional Movement Screen

(FMS)

Diagnostic tool designed to test a patient’s movement patterns and compare those patterns to an established minimum standard Assess quality of movement Highlight movement pattern limitations and asymmetries

Complement to other movement assessments – impairment measures (MMT) or functional performance measures (10MWT) Provides a more complete picture of dysfunction rather than

snapshots of isolated impairments Injury leads to altered motor control globally

Appropriate Application

SFMA is not always the most appropriate assessment Acute trauma or post-surgical

Conditions dominated by swelling, bruising, inflammation If these are present in sub-acute or chronic conditions, it

should be managed prior to corrective exercise involving active movement

New neurological compromise

In these situations, other examinations are more important

Once these conditions are managed, the SFMA can be utilized to determine the effects on movement

Objective Grading of Movement

Functional, Nonpainful – FN “The Dead End” This pattern is not the weak

link Do not spend time breaking

out this pattern- will only find insignificant limitations

Functional, Painful – FP “The Marker” Confirms that pain is

affected by movement Revisit the marker to assess

change or variation Don’t need to exercise this

movement because it’s functional

Dysfunctional, Nonpainful – DN “The Corrective Exercise Path” Focus on these patterns Exercise-based treatment can

be applied in this pattern without risk of exacerbating pain or reinforcing dysfunctional patterns

Dysfunctional, Painful – DP “The Logistical Beehive” Breakouts can reveal FP or DN

patterns Difficult to interpret – Is pain

causing poor movement or vice versa?

Don’t attempt corrective exercise in this pattern unless it’s a last resort

Top-Tier Assessments

Patient should be able to touch sternum with chin without pain

Patient should be able to get within 10 degrees parallel without pain

Top-Tier Assessments

Patient should be able to reach mid-clavicle bilaterally without pain

Patient reaches back with the arm trying to touch the inferior angle of the opposite scapula

Top-Tier Assessments

Patient reaches overhead with the arm trying to touch the spine of the opposite scapula

Patient places palm on opposite shoulder and lifts the elbow to the sky

Top-Tier Assessments

Patient uses hand to help passively while horizontally adducting the opposite arm as far as possible

Patient bends forward at hips trying to touch the ends of the fingers to the tips of the toes without bending the knees

Top-Tier Assessments

Patient bends backwards as far as possible, making sure the hips go forward and the arms go back simultaneously

Patient rotates the entire body – hips, shoulders, head – as far as possible to one direction while foot position remains the same

Top-Tier Assessments

Patient lifts one leg so the hips and knee are both at 90 degrees and holds for 10 seconds

Patient slowly descends as deeply as possible into a squat position

Why Treat the DN?

FNThe Dead

End

FPThe Marker

DNThe

Corrective Exercise

Path

DPThe

Logistical Beehive

+ Motor control remains altered due to past injury

+ Altered hip, hamstring & ankle musculature activity following ankle injury 2, 3, 4

+ Altered sit-to-stand movement pattern 1 yr post-TKA 5

+ Greater muscle response and delayed latency following anterior, posterior or lateral perturbations in athletes with recent history of low back pain6

+ Pain alters motor control7

+ Motor control changes are somewhat unpredictable and may be task specific- 8, 9

+ In the induced pain group:

+ Arm lift increased multifidus firing on EMG8

+ Weight shift decreased multifidus firing on EMG8

+ Decreased agonist and antagonist activity due to pain10

+ Reduced movement amplitudes7

+ Decreased agonist activity compared to antagonist activity

Hierarchy of Treatment

Once you’ve discerned which DN pattern to begin with, 3 filters guide treatment within the pattern breakout: Limitation

Resolve the greatest limitation first Could also pick the pattern with lowest physical demand or simplest pattern

Asymmetry Resolve asymmetrical limitations before symmetrical limitations

Redundancy Test/retest patterns and be aware of inconsistencies

Return to the next most significant limitation or asymmetry once the first is resolved

Cervical DN

Shoulder DN

Forward or

Backward DN

Rotational DN

Single Leg DN

Squatting DN

Stability vs. Mobility

STABILITY PROBLEM

Loaded and unloaded movements are not equal

Passive movement is substantially greater than active movement (10° rule)

Inconsistent findings

SFMA global dysfunction terminology for a stability problem: SMCD- stability &/or motor

control dysfunction

MOBILITY PROBLEM

Loaded and unloaded movements are equal

Passive movement is only slightly greater than active movement (10° rule)

Consistent findings

SFMA global dysfunction terminology for a mobility problem: TED- tissue extensibility

dysfunction JMD- joint mobility dysfunction

Breakouts

Treatment Hierarchy Rationale

Each level of movement plays a role in the next

In the context of permanent restriction (surgical fixation, extensive scarring, etc) this hierarchy might need to be altered

Exercise interventions not directed at painful movements Still treat pain but not with exercise

Utilize exercise to retrain dysfunctional movement instead

This paradigm requires buy-in on the part of the PT and patient Ex. “Why are you treating my neck when my shoulder hurts?”

“Transforming society by optimizing movement to improve the human

experience.”

REVISED APTA VISION STATEMENT

To Learn More…

Movement: Functional Movement Systems by Gray Cook

www.functionalmovement.com

SFMA certification courses and workshops

Printable flow sheets for use during SFMA examination http://graycookmovement.com/downloads/SFMA%2

0Score%20Sheets.pdf

References1. Cook, Gray. Movement: Functional Movement Systems. 2010. On Target Publications: Santa Clara, CA.

2. Hubbard, TJ. Kramer LC, Denegar CR. Hertel J. Correlations among multiple measures of functional and mechanical instability in subjects with chronic ankle instability. Journal of Athletic Training. 2007; 42 (3): 361-366.

3. Beckman, SM. Buchanan TS. Ankle inversion injury and hypermobility: effect on hip and ankle muscle electromyography onset latency. Arch Phys Med Rehabil. 1995; 76: 1138-1143.

4. Van Deun, S. Staes, FF. Stappaerts, KH. Janssens, L. Levin, O. Peers, KKH. Relationship of chronic ankle instability to muscle activation patterns during the transition from double-leg to single-leg stance. Am J Sports Med. 2007; 35 (2): 274-281.

5. Farquhar, SJ. Reisman, DS. Snyder-Mackler, L. Persistance of altered movement patterns during a sit-to-stand task 1 year following unilateral total knee arthroplasty. Phys Ther. 2008; 88: 567-579.

6. Hodges, P. van den Hoom, W. Dawson, A. Cholewicki, J. Changes in the mechanical properties of the trunk in low back pain may be associated with recurrence. Journal of Biomechanics. 2009; 41 (1): 61-66.

7. Arendt-Nielsen, L. Graven-Nielsen, T. Muscle pain: sensory implications and interactions with motor control. Clin J Pain. 2008; 24 (4): 291-298.

8. Kiesel, KB. Butler, RJ. Duckworth, A. Halaby, T. Lannan, K. Phifer, C. DeLeal, C. Underwood, FB. Experimentally induced pain alters the EMG activity of the lumbar multifidus in asymptomatic subjects. Man Ther. 2012; 17 (3): 236-240.

9. Ahern, DK. Follick, MJ. Council, JR. Comparison of lumbar paravertebral EMG patterns in chronic low back pain patients and non-patient controls. Pain. 1988; 34: 153–160.

10. Ervilha, UF. Arendt-Nielsen, L. Duarte, M. Effect of load level and muscle pain intensity on the motor control of elbow-flexion movements. Eur J Appl Physiol. 2004; 92: 168–175.