Begin with the End in Mind Habit 3: Put First Things First

Here is how the habits apply to the correct use of the SFMA.

SFMA Habit 1

You are being proactive since you are consid-ering movement patterns for both dysfunction and pain provocation. The central purpose of the SFMA is to set a functional baseline for the course of rehabilitation and provide a systematic ap-proach for the introduction of corrective exercise.

Continuing the proactive theme: You have decided not to assign exercise based only on anatomical regions of impairment or generalized medical diagnosis. You will use movement patterns as a guide, and you have also considered the highly individual movement map that displays the unique perceptions and movement behaviors of each patient individually. This proactive professional act removes protocol- based corrective exercise and replaces it with an approach developed in direct complement to movement dysfunction while avoiding the complicating issues of pain provocation during corrective exercise.

SFMA Habit 2

You have chosen to begin with the end in mind.

You have not assumed all movements that are non- painful are functional. Likewise, you have not assumed all movements that are painful are dys-functional. You have set a professional minimum

Overhead Deep Squat Start

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standard for functional movement patterns in active populations, and you have decided to set goals based on functional movement patterns. You understand that addressing movement dysfunction is a valued service to patients entrusted to you, and it may be their only opportunity to have a complete functional movement- pattern assessment.

Movement- pattern dysfunction is emerging as a risk factor. Whether you are addressing dys-functional patterns to improve a patient’s current condition or simply reducing future risk, you are beginning with a compressive end in mind.

Choosing to address the dysfunction is ultimately a clinical decision dictated by each individual case.

As a movement specialist, your role is to inform, educate and offer treatment when appropriate.

The SFMA can potentially form a link between a functional clinical perspective and a return to a more active lifestyle.

SFMA Habit 3

You have a new system and it actually comple-ments the habit first things first, but sometimes you need two hierarchies. The first hierarchy removes the SFMA as an option altogether. The second ap-proaches the hierarchy of the SFMA itself.

Hierarchy 1

Corrective exercise involving active movement is not indicated.

Not all rehabilitation situations warrant an SFMA. Acute trauma and post- surgical situations are complicated with chemical pain. This chemical pain is a result of inflammation, swelling, effu-sion, eccymosis and muscle guarding. Likewise, sub- acute and chronic conditions can also display levels of chemical pain that must be managed prior to corrective exercise involving active move-ments. The SFMA would also not be appropriate if an upper- or lower- quarter neurological scan or screen of dermatomes, myotomes, deep tendon reflexes or other testing reveals neurological com-promise that was not part of the current diagnosis.

In situations of chemical pain and neurological compromise, appropriate treatment or further testing is more important than the map the SFMA can provide. The map would obviously be

incomplete at best, and it would also incorporate movement dysfunction driven by clinical issues outside of non- irritable mobility and motor control limitations. Once these issues are effec-tively managed, the SFMA can be performed to better understand how movement patterns have been affected.

Some clinicians are often confused when the SFMA is not indicated on the normal intake examination, but sometimes it simply is not ap-propriate. The clinical application of corrective exercise should be the driver of the SFMA. It should be used prior to corrective exercise decisions and dosage. The SFMA assumes that serious medical issues like active chemical pain and neurological compromise have been effectively managed.

Hierarchy 2

Corrective exercise involving active movement is indicated.

The SFMA uses a hierarchy that introduces movement patterns that build on each other. The levels of movement- pattern involvement becomes more complex and progressively involves more anatomical regions and higher levels of motor control.

Obviously, it does not totally mirror the human developmental progression, but many of the principles are present. The SFMA begins with movement patterns of the cervical spine and moves to the shoulder movement patterns. This suggests that if both are found to be DN patterns, the cervical spine should be considered first. If possible, it should be managed to understand its influence on the shoulder movement patterns even if the shoulder patterns display more pronounced dysfunction. This in no way suggests the shoulder patterns should not be broken down or managed—

it just implies that if both are treated and exercised simultaneously, it would be hard to attribute inter-vention to outcome.

Likewise, if a DN were noted in the shoulder movement pattern, it would probably influence the outcome and breakout information collected in the rotation patterns. Aggressively breaking down the rotation pattern and attempting correction before

The Art of Balancing Movement and Pain Information managing the shoulder patterns would be

inap-propriate. This does not suggest that the shoulder DN must be completely corrected; it indicates a segment involved in a larger movement pattern can be improved and therefore has influence over the larger pattern.

The hierarchy is part of the system to improve the clinical survey of regional interdependence.

If multiple areas were initially managed simul-taneously, this would reduce the observation of interdependence. Therefore, perform top- tier tests and note all DNs, as well as their degree of dysfunction. Address dysfunction within the hi-erarchy within time and treatment constraints. If the hierarchy is not followed, all information must be considered and qualified against an existing limitation.

Example

The forward bending pattern might be the most obvious and dysfunctional DN limitation, but the cervical spine flexion pattern is also limited. The hierarchy suggests the C- spine should be addressed first if it can be done practically. Therefore, the C- spine pattern is broken down. Limitations are noted in the soft tissue and articular structures of the upper cervical spine. Following three minutes of mobilization and soft tissue work, the C- spine pattern is considered FN. When the forward bend top- tier test is repeated, three outcomes are possible.

FN— The C- spine tone was driving the limitation in the forward bending pattern. This is a common finding and demonstrates how the forward bending pattern incorporates the C- spine flexion pattern. Therefore, if it is also represented, it should be managed to remove its influence.

DN, partially improved— The C- spine tone was a partial influence and now the forward bending pattern can be broken down without complicat-ing factors of the C- spine. This is also a common finding.

DN— The C- spine DN was an independent factor. The forward bending pattern can now be investigated without hierarchical consideration of the C- spine since the DN has been removed.

If the C- spine DN cannot be improved or managed, it must be considered a contributing factor since it cannot be ruled out. In this situa-tion, it would be appropriate to break down the forward bending pattern, but the C- spine should be monitored and managed over the course of rehabilitation within the scope of the patient's condition and lifestyle.

This hierarchy assumes a clinical skill set is in place to efficiently and effectively manage DNs through manual techniques involving facilita-tion and inhibifacilita-tion. Otherwise, the suggesfacilita-tion to manage multiple DNs might seem overwhelming.

If it can be agreed that the basic logic is correct, the limitation would be the skill set.

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The Selective Functional Movement Assessment (SFMA®) breakouts systematically dissect each of the major pattern dysfunctions described in the previous chapter. The hierarchy will dictate your investigation of all top- tier patterns scored as Dys-functional and Non- Painful (DN), Functional and Painful (FP) or Dysfunctional and Painful (DP). It is most efficient to break out all DNs before testing the FPs and the DPs. You should test the DPs last since they can lead to further tissue inflammation and exacerbation of the symptoms. Breaking out the DPs can make further testing impossible or extremely uncomfortable for the patient.

The breakouts will either test all areas involved to isolate limitations or determine dysfunction by the process of elimination. The breakouts include active and passive movements, weight- bearing and non– weight- bearing positions, multiple- joint and single- joint functional movement assessments and unilateral and bilateral challenges.

The SFMA provides user- friendly testing to demonstrate large discrepancies between active and passive abilities whenever it can be efficiently performed. The breakouts are also performed to improve the efficiency of the SFMA decision tree.

These assessments are mostly global, non- measured appraisals and are used to suggest the need for further clinical investigation. These tests prove a logical connection between functional movement and impairment measurements. The breakouts should never be considered a terminal point unless they provide negative information and no other risk factors are present.

In general, reduced movements seen in passive assessments suggest that mobility problems are likely. However, these must be confirmed with spe-cific local testing. In contrast, normal motion in passive assessments suggests that potential mobil-ity problems are unlikely. Once again, this can only

be confirmed with specific local testing. A stability problem might be likely when active movement is limited in loaded or unloaded positions, or both, and when passive testing is normal.

In all cases, the SFMA will suggest that you perform local biomechanics testing to confirm normal range or that you clinically measure the level of mobility impairment. Biomechanical testing should also include appraisals of struc-tural and neuromuscular integrity as well as motor control. The biomechanical tests should indicate if impairment is present or absent and help complete the functional diagnostic process. Local biome-chanical testing is beyond the scope of the SFMA, used to specifically measure mobility with gonio-metric measurements, structural integrity with manual muscle testing, neuromuscular integrity and motor control. These tests should indicate if impairment is present or absent and should help complete the functional diagnostic process.

ADDITIONAL TERMINOLOGY