The Selective Functional Movement Assessment (SFMA) is a systematic method that focuses on whole body movement patterns. You might be familiar with the Functional Movement Screen (FMS) created by the same group. The FMS is a screen that can be used by any fitness professional. The SFMA is a diagnostic system (that can only be performed by medical professionals) similar to that of McKenzie. At the core of the SFMA is the concept of regional interdependence, "seemingly unrelated impairments in a remote anatomical region may contribute to or be associated with the patient's primary complaint." The assessment is broken into 7 Top Tier tests and graded as Functional and Non-painful (FN), Functional Painful (FP), Dysfunctional Non-painful (DN), and Dysfunctional Painful (DP). If a Top Tier test does not pass the FN grade, then that specific movement must go to a breakout pattern to find the true cause of dysfunction. To simplify things, the "true cause of dysfunction" can either be viewed as a mobility (Tissue Extensibility Dysfunction (TED)/Joint Mobility Dysfunction (JMD)) OR a Stability/Motor Control Issue (SCMD). Below is an example of Chris performing the Multi-Semental Flexion Top Tier Test with demonstration of the appropriate breakout patterns following. In the Multi-Segmental Flexion Top-Tier test, have the patient bend forward to touch their toes. The person assessing the movement should be looking for a uniform spinal curve, the thoraco-lumbar junction ending up over the feet, a sacral angle >70 degrees, and the ability to touch the toes without excessive exertion. If the person passes all the listed criteria, they are considered FN! Otherwise they are graded as DN, DP, FP and the Multi-Segmental Flexion breakout needs to be performed. As you can see, Chris is unable to touch his toes, so he is immediately given a DN (the motion was pain-free). At this point, we know they have some type of dysfunction. Whether it is a posterior chain extensibility issue or motor control issue, we are not sure. Therefore we must continue with the assessment. The next video (below), demonstrates the Single Leg Forward Bend. This will give you a sense if the dysfunction is symmetrical or not & if a single leg movement produces pain. In order to "pass" this test, the same criteria as above need to be fulfilled. All this test really tells you is if there is an asymmetry or not. As you can see below, Chris' movement is still DN, so the breakout continues (it would continue even if he received a FN). At this point, we know Chris has a dysfunctional movement pattern in standing so we need to see if the movement changes when he is placed in NWB. This tells us if he simply has a postural control issue. The next test (seen below) is the Long Sitting Test. To pass this test, Chris needs to touch his toes, have a sacral angle of at least 80 degrees, and have a uniform spinal curve. You will see in the video that he cannot touch his toes and the sacral angle does not reach 80 degrees. He has no pain, so the movement is graded DN. Hypothetically at this point, if Chris were to have passed (FN), we could assume he has a SMCD due to an issue with postural control because he is able to perform the motion once the effects of spinal loading have been reduced. He would then proceed to the Rolling component. Since Chris is unable to complete the motion when postural control is decreased, we now break apart each component of the motion to determine where the fault lies. To first assess the lower extremity component, we move to the Active Straight Leg Raise (seen below). This motion assesses the motor control/stability to actively flex the lower extremity, provided there is sufficient range. A minimum of 70 degrees of hip flexion is required. Be sure to watch that the contralateral thigh stays down and the knee remains extended on both legs. As you can see, Chris does not reach 70 degrees, so he receives a grade of DN. If Chris were able to complete this motion, we would know that Chris has adequate tissue/joint mobility and motor control in his lower extremities. We would then move on to the Prone Rocking Test. With Chris failing to pass the Active Straight Leg Raise, we must now move onto the Passive Straight Leg Raise to determine if the tissue/capsular length even exists for the motion to complete. A passing score would require 80 degrees of hip flexion (with the same precautions in the active test). Chris again does not pass the test (DN). If he had passed this test, we would then proceed to Rolling. After determining that there was a TED or JMD limitation, we can now use the Supine Knee to Chest test to determine if it is a 1 joint or 2 joint limitation (it could potentially be both). As you can see with Chris, he has a 1 joint limitation for sure (he likely has a 2 joint deficit as well) - DN. This positive test may indicate capsular hypomobility, decreased length of the gluteus muscles, or decreased neural mobility (or a combination). This is a location for treatment with Chris. Going back to the Active Straight Leg Raise Test, had Chris passed it he would have proceeded to the Prone Rocking Test below. With the lower extremity component of the Multi-Segmental Flexion Top Tier Test ruled out, we now need to assess the other primary component: lumbar flexion. A passing test requires a uniform curve and the thighs pressing against the lower rib cage. With the lower extremity motion already cleared, we now know the restriction if located in the lumbar spine as a TED or JMD. With the video below, it appears Chris receives a DN, but remember he had limited hip flexion, which can cause a false positive here. As you can see, the sequencing is important! Assuming this test receives a FN, we once again proceed to Rolling. Had your patient had a DN score here, this would again be a location of treatment for JMD or TED. Finally we arrive at the rolling pattern. once we have shown that adequate joint/tissue mobility is present for the required pattern, we can assess motor control patterns with this breakout. Look for your patient's ability as to whether or not they can complete the flexion rolling patterns. The motions should be smooth with dissociation of each component (you should not see log-rolling). Limited mobility anywhere in the chain can cause pauses or difficulties completing the motion (i.e. decreased cervical rotation could easily inhibit normal rolling, especially since it is the starting point for UE flexion rolling. Rolling can be scored just as the other tests. FN requires pain-free smooth rolling with no difficulty, pauses, or inability to dissociate the components - any of these lead to DN. DP and FP follow the usual scoring roles as well. Hopefully this gives you an idea of what the SFMA offers as a method of doing examination. This doesn't mean you should exclude your strength tests, special tests, neuro screens or even ROM measurements for certain patient populations. In a way, this method is even more objective than a goniometer allows due to the system's utilization of actual landmarks for completion. A goniometer may still have a place where regular progress is required (i.e. surgical patients, adhesive capsulitis, etc.). Instead this system can help to gain a very detailed look at each patient and ensure that you don't miss anything significant. Your patients often will comment how thorough you are (making you look like an even better PT!). The rest of the SFMA has a similar process of going through joint-by-joint assessments of motion and stability for the rest of the body as well. If you are interested in this, you may want to take the SFMA course. Gray Cook's book Movement details the system as well; however, the system has actually been updated since the book was written and is much more thorough and appropriate now. This method of examination has helped us to better determine the best locations for treatment and other potential causes to dysfunction. If you have any questions, do not hesitate to ask!
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The next issue is the lack of research on exam measures and intervention techniques that we use in the clinic. We have had our mentors and fellow clinicians comment on where the evidence is for some of our treatment styles. A perfect example is Instrument Assisted Soft Tissue Mobilization (IASTM). While there is some initial research out there currently, there is hardly enough evidence to prove that IASTM is a high-quality, proven treatment. That being said, the results can be impressive. The key comes back to test and re-test your patients after a treatment. This applies to more than just IASTM. With your corrective exercises, joint mobs/manips, etc., assess your patient first (pain, ROM, strength, symptoms, SFMA) and re-check afterwards. Going back to IASTM, we have had particular success improving ROM without neural provocation using IASTM. Utilizing the neural tension test as our base and then follow-up, we have seen gains in ROM by as much as 45 degrees after simply a few minutes of IASTM. Basically, if you can prove that a treatment works by doing this, why stop it? Of course, we can't forget about incorporating these changes into our care and reinforcing them to lock in the changes, but the lesson is we shouldn't limit ourselves by what the literature is (or isn't) saying at the time.
Something we are likely to be asked by our patients is "When can I return to driving?" This study showed that there is no specific time frame for return from joint replacement surgery. Any recommendations may result in patients either being restricted for too long or too little. The APTA Orthopaedic Section's Current Concepts on Hip Management recommends at least 4-6 weeks before returning to driving after surgery. Some obvious considerations include medications the patient is taking (as this may impair decision making, awareness, and reaction time), left versus right surgery (the left foot is typically not used for driving), and force production. With the inconsistent findings in the latest research, it would appear there is a need for further research in the area in order to be able to best determine when patients can safely return to driving. Have you ever found yourself talking with Medical students or even doctors and wanted to give them some advice regarding referrals, treatments, or pathology in general. Well we definitely have been in this situation. Many medical school programs receive no formal education in Kinesiology or Biomechanics. As therapists, our scope on knowledge on regional interdependence in much greater. Specialists in Sports and Ortho Rehab (SSOR) recently came out with a post regarding 10 tips on how to educate primary care students/ residents/ fellows. The 10 tips are listed below, but check out the full post for in depth reading on the topic. 1. Shoulder pain can be disguised as neck pain (and vice versa). 2a. Not all tendinopathies are the same. 2b. Eccentric exercises can be a promising intervention for certain tendinopathies. 3. Signs and symptoms of mensical tears. How to spot them during your physical exam! 4. For people with general knee pain, address the hip abductors and external rotators. 5. Headaches can be treated by physical therapists. 6. Sciatica can be managed by postural education, core strengthening, nerve glides, and hip strengthening. 7. Carpal Tunnel isn't always just in the wrist. 8. In acute ankle sprains, give your patients an assistive device before having them walk around with a limp. 9. In patients with low back pain or SI pain, the problem may not be in the back. 10. Modalities are misused and abused, and frankly, there is little evidence supporting them. These points may all seem very obvious to physical therapists, but they may not be so clear to everyone else. For example, how many times have you had a referral for low back pain when the cause of the dysfunction was not the low back at all. This is a good top 10 list, but it is not a complete list. Can you think of other beneficial tips on how to educate medical students/residents? Outcome Assessments! In school we learned hundreds of different outcome measures: Measures for Fear Avoidance, Fall Risk, Disability, Quality of Life, and more. Everyone hears about them, but who actually uses them? According to a study by Jette et al, 48% of therapists used standard outcome measures. Personally, we thought this figure was slightly ambitious, but the even more unfortunate figure was that of the 52% of participants who did not use outcome measures, 49% stated they did not intend to incorporate them into their clinical practice in the future. Reasons for the lack of participation included the measures are too time consuming, too difficult for the patient to fill out individually, and too time consuming to analyze and calculate the results. While we do not agree with these excuses, we do understand the added workload in using certain Outcome Measures. Let's not focus on why we do not use them, but rather point our attention to why we should incorporate them more regularly. First, they can be an excellent tool to give the practitioner objective data that he/she can utilize in goal setting and prognosis. The assessment will paint a clinical picture of the patient's functional ability and open up communication between the PT and patient to discuss how the patient perceives his/her current status. Second, payers want to see them! Even if you are not satisfied with using them, CMS for example is "recommending" that patients fill particular outcome measures that directly link to functional limitations. The guidelines with which we get reimbursed are becoming much more stringent. These assessments are an objective means of showing improvement. Whether you like it or not, our field is progressing to a pay-for-outcomes profession. Finally, if we ever expect to gain autonomy in clinical practice, we need to show consistent objective data that our treatments have a true impact on the patient's function. Currently there are several very sophisticated outcome measures, such as FOTO, that give you information about a patient's fear avoidance, expected number of visits, expected improvement, and more. We need to continue to use these measures to standardize practice! As we mentioned at the beginning, there are hundreds of different outcome assessment to choose from. Memorizing them would not be beneficial. Rather you should know where to find them and how to interpret them. The following are two great resources that give you access to a number of familiar (and some unfamiliar) assessments you are likely to encounter. Rehabmeasures.org Physio-pedia.com While relatively new to the field of Physical Therapy, Clinical Prediction Rules have been used in medicine for a very long time (for example the Deep Vein Thrombosis CPR). These rules have been designed to improve clinical decision making and assist the practitioner in diagnosis, prognosis, and intervention planning. Childs and Cleland point out that "CPRs provide practitioners with powerful diagnostic information from the history and physical examination that may serve as an accurate decision-making surrogate for more expensive diagnostic tests." Not only can CPR's help curb the rising costs of healthcare, using this high level of evidence is especially important in the direct access setting where more extensive diagnostic testing has not been performed. In addition to diagnosis, other CPRs can aide in the classification and subgrouping of patients to guide you in intervention planning. Now that you know CPRs are important, what are these clinical prediction rules and where can you access them? Fortunately John Synder at the Orthopedic Manual Therapist recently compiled a list of them. Check them out HERE! References:
Childs J and Cleland J. (2006). Development and Application of Clinical Prediction Rules to improve decision making in Physical Therapist Practice. PHYS THER. 2006. Jan;86(1):122-131. Web. 13 Aug 2013. The average adult breathes 12-20x/minute, which accounts to over 20,000 breaths/day. Ideally, the diaphragm is the major muscle of inspiration. When abnormal breathing patterns develop, accessory muscles (scalenes, SCM, upper trapezius, pectorals) are forced to be used more. In other words, these muscles have the potential to be used improperly >20,000x/day. Scary right?! While various breathing pattern abnormalities exist, a commonly seen pattern is the "chest breather." The chest breather does not fully engage his/her diaphragm and often has decreased lung volumes. These patients often incorporates their anterior accessory muscles of inspiration which can pull them into a forward head and rounded shoulder posturing: a posture we see in many of our clients. Their imbalances go deeper than what is seen by observation alone. Because the chest breather has decreased lung volumes, he/she may be in a constant sympathetic state to supply sufficient oxygen to the bodies tissues. Consequently, they may have increased muscle tone, anxiety, and a variety of other PNS and CNS symptoms. In a post written by Mike Reinold in late April, he highlights two studies that show the importance of proper breathing. One study interestingly discovered increased EMG activity of the scalene and trapezius muscles while typing. As students, who spend most of their day at a computer, this is something to consider. This could be contributing to neck pain and stiffness that so many students have. Additionally, breathing exercises maybe a good place to start for your sedentary office worker with chronic neck pain. Reinold also mentions several treatment strategies to initially assess breathing technique: 1. Breath Holding Test. Decreased breath holding my demonstrate an intolerance to CO2 build-up. 2. Belly/Chest Test. Have the patient place one hand at their naval and their second hand at the sternum. Assess which hands moves further. Is there a change is sitting vs. supine? With a deep breath, ~90% of motion should come from the lower hand, indicating good diaphragmatic breathing. This test can later be used as an intervention. It is a simple way to provide external cueing to the patient to activate their diaphragm. 3. Seated Lateral Expansion. Have the patient place a hand on either side of their thorax. Take a deep breath in and feel for rib movement symmetry. Again, if one side is moving differently than the other, hand cueing + manual facilitation can act as a good treatment intervention early in the POC. Below is a basic video demonstrating diaphragmatic breathing: Here are 2 other good resources we found off Dr. E's website (The Manual Therapist) on breathing:
1. 5 Techniques to try with Diaphragmatic breathing 2. Assessment and Treatment for Diaphragmatic Breathing by: SPT Fred Charles Thanks Mike Reinold and Dr. E for the great posts! We found this gem recently posted on the ilovephysicaltherapy blog by Stelios Kolomvounis. MIT OpenCourseWare offers over 2,100 courses, which can be selected by topic or department. There are not too many PT specific courses yet, but MIT offers a variety of other topics available to the public for free! Check it out at the link below: http://ocw.mit.edu/courses/find-by-department/ Credit goes to Julie Wiebe for posting this interesting abstract. Overactive Bladder Syndrome (OAB) is a disorder of urgency, frequency, nocturia, and possibly incontinence. This post stood out to us, because the study demonstrated the potential for treating OAB by stimulating the posterior tibial nerve. By inhibiting somatic lumbar and sacral nerve fibers, the detrusor muscle is inhibited without any alteration in the micturition reflex. The study found both ES to the pelvic floor and PTNS to be effective in modulating the effects of OAB; however, ES was found to be superior overall. Yet, it is still interesting to see the effects we can have on the renal system by working peripherally with e-stim. This is something we should consider when treating our patients, for both the potential positive and negative side effects. In the clinic, we often only have the length of the gym to analyze a patient's gait pattern. They patient may walk back and forth 2-3 times, giving you a total of 30 seconds to 1 minute to fully assess their pattern and recognize any deviations. In this post from the Physioblogger, he discusses his Quick Gait Assessment. His assessment includes looking at the feet, hips, and trunk. He starts at the feet and works cephalad. Beginning at the feet, he assesses heel to toe progression and the amount of pronation/supination. Next at the hips, he analyzes frontal plane motion and the amount of pelvic sway. Finally in the thoracic region, quick notes are made on the amount of arm swing and trunk stiffness. Important points: -No diagnosis is made during the gait assessment. Formulating hypotheses as to why a deviation is present is fine, but do not make definitive judgements as to why deviations are occurring. It is simply an observation. -Always remember a patient's injury, mechanism, lifestyle. What structures are involved? How can this injury/ their lifestyle impact the gait cycle? -If possible, videotape your patients! Watch their gait patterns after they are gone. Take a few notes, perform the appropriate tests and measure, and act accordingly! Everyone has a different system they use for their quick gait assessment. Having a consistent method and practicing that method is important to your success as a therapist. Remember, we are movement analysis specialists. |
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