SFMA: Multi-Segmental Flexion and Breakouts

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!