During my final clinical rotation, I was located at an outpatient ortho setting where I was required to do an inservice for the employees. After observing a few of the PTs perform their examinations with a set system focused on the area of symptoms, I knew what I wanted to do my inservice on: the Selective Functional Movement Assessment (SFMA). The more experience I obtain in the ortho setting, the more I have come to realize the potential contribution other joints have on the pathology and the importance of including them in our examinations. Sometimes it seems pretty obvious when a distal or proximal joint is affecting the patient's symptoms, but we should be checking these joints on a routine basis with our examinations. The SFMA is not to be confused with the Functional Movement Screen (FMS), also created by Gray Cook. The FMS is a screen for musculoskeletal risk of injury that can be performed by any fitness professional. It consists of seven movements graded on a scale of 0 - 3. Any provocation of pain requires referral to a medical professional. The SFMA is a method of orthopedic examination, which often involves painful movements, that can only be performed by a licensed medical professional. The SFMA provides a baseline that can show any changes in movement patterns following treatment. It is an objective method that some may utilize instead of goniometric measurements. The most significant part of the SFMA is that it's a standard sequence the takes into account the whole body. The reason the standardized sequence is so important is that it lowers the likelihood of us leaving something out, missing the possibility for potential regional interdependence.
The SFMA's grading system is similar to that developed by Cyriax. Cyriax's grading consists of:
-Strong and Painless (normal)
-Strong and Painful (a minor lesion in the tissue)
-Weak and Painful (a major lesion in the tissue)
-Weak and Painless (a neurological issue)
The SFMA grading system is:
-Functional and Non-Painful (FN)
-Functional and Painful (FP)
-Dysfunctional and Non-Painful (DN)
-Dysfunctional and Painful (DF)
Functional movement corresponds to unlimited and unrestricted movement that a patient is able to complete with one breath cycle at end range. If breathing alters the movement, it is dysfunctional. FP is a marker for pain that can be reassessed throughout treatment. Typically, corrective exercise would not be appropriate here, because movement is within normal limits. DP has both limited movement and pain. It is key to breakdown these movements to find the source of each. Corrective exercises aren't used here either. DN is simply limited movement. Again we can break down the movement to find the source of the limitations. This is the key to utilization of corrective exercises and where we should focus our treatment. Changes here may lead to changes elsewhere. When a patient has multiple DNs, they should be addressed in a top-down format (cervical before shoulder, etc.). If a patient has a DN as a result of permanent restriction, surgery, etc., the DN should be discounted. There are three main things we should consider regarding the SFMA results: limitation, asymmetry, and redundancy. Choose the pattern with the greatest limitation. Asymmetrical limitation should be addressed before symmetrical limitation. The SFMA has built in redundancy to ensure the true motion of a joint.
Just as goniometric range of motion measurements are not a diagnosis, SFMA scores are not a diagnosis. They are simply a marker for both movement and pain that we can regularly check for changes to see the effect of our interventions. We should focus our interventions on FP and DN. The SFMA consists of several Top Tier Tests that can be broken down into additional patterns based on the findings to help determine the source of the limitation. The Top Tier Tests include: Cervical Patterns 1, 2, 3; Upper Extremity Patterns 1, 2; Multi-Segmental Flexion; Multi-Segmental Extension; Multi-Segmental Rotation; Single-Leg Stance; Overhead Squat. Given an abnormal finding, such as FP, DN or DP, for one of the Top Tier Tests, we go into the Break Out Patterns. The Break Out Patterns look at each separate joint in an standing active position, supine active position, and supine passive position. This puts various loads on the movement to determine if the limited movement is due to deficits in mobility, stability, or both.
The Cervical Top Tier Tests consist of three movements in standing: cervical flexion (chin to chest), cervical extension, and cervical rotation/sidebending combined (chin to mid-clavicle). If these result in FP, DN, or DP, proceed to the Cervical Break Outs. These consist of several movements in supine: active cervical flexion (chin to chest), passive cervical flexion (chin to chest), OA cervical flexion test (20 degrees), active supine cervical rotation (80 degrees), passive cervical rotation, C1-C2 cervical rotation test, and cervical extension. These movements allow the clinician to determine which part of the cervical spine is leading to dysfunction. This is just an example of how a Top Tier Test is broken down. For a patient, it is necessary to do a full SFMA examination based on the patient's findings. This may mean only having to perform one set of Break Outs or Break Outs for each Top Tier Test. Note: I am not credentialed in the SFMA. These explanations come from Gray Cook's Movement. For more information on these topics, I recommend either reading Cook's book or attending the courses on the matter. Also, check out this interesting case by The Manual Therapist that shows the usefulness of the SFMA in identifying regional interdependence in patients!
Cook, G. (2010). Movement. On Target Publications.
James Heafner DPT, Chris Fox DPT, and Brian Schwabe DPT, CSCS are recent graduates of Saint Louis University's Program in Physical Therapy.