Recently, several colleagues at our clinic participated in a meeting, a sort of grand rounds to facilitate discussion between colleagues who are more seasoned users of Selective Functional Movement Assessment (SFMA) methodology and those who have only recently taken the level one course. Thankfully, we have the opportunity to put our heads together once a month. The irony is that, despite the SFMA providing a systematic and algorithmic (albeit very detailed) approach to patient assessment and treatment; points of diminished clarity and precision in patient assessment and treatment priority were uncovered. Some of that likely stems from the fact that everyone took the courses from different instructors and seasoned their learning experiences with variable prejudice and personal fitness experience. Additionally, all but two of us had variable introduction to corrective exercise implementation (4x4 matrix). Given the breadth and depth of the paradigm, some variability is expected in initial treatment strategies (i.e. breaking out flexion vs. extension when the patient demonstrates similar degrees of dysfunction, perhaps with extension appearing slightly more dysfunctional). However, the end-result should be the same: correction of fundamental, functional movement impairments.
The SFMA is best used by initially accepting the hypothesis that correcting the “big 7” fundamental movements will facilitate pain relief and optimize performance via improved motor control and ROM. The relevance of functional and painless toe touch or “multi-segmental flexion”, for instance transcends the “I’m a runner; I haven’t been able to touch my toes since I was eight. That isn’t why I’m here?” argument. In fact, as we’ve seen multiple times, some of these folks have back pain with running. The theory behind SFMA is that pain causes compensation and dysfunctional movement (defined by the big 7) over time. As an example, back pain has been shown to cause delayed activation of gluts, Transversus Abdominus and lumbar multifidi (even after pain has stopped). Theoretically, the compensatory motor control pattern is overuse of hamstrings and paraspinals, which restricts forward bending ROM. Therefore correcting this pattern is a big step in optimizing motor control. Using proper corrective exercise prior to running, in addition to utilizing cross training to promote hip drive and core motor control , are often viable means of eliminating back pain with running in these cases.
While this is a fairly detailed (yet by no means comprehensive) example of support for the SFMA, the clinician doesn’t need to wrap his head around the details, but only “trust the system.” The first priority is always treating any asymmetries. Closely behind is cleaning out major dysfunctional patterns then treating from a top-down approach, beginning with cervical patterns. Advance through the 4x4 matrix to standing, then advance to functional activities, such as the deadlift or adding load and volume to the overhead squat. To quote Gray Cook, training a deadlift when someone is unable to touch their toes or adding load to an improper squat “is adding fitness to dysfunction.”
We correct asymmetries first for one primary reason. Asymmetries are correlated to injury. This has been seen in several studies including: in the lower extremity, strength and flexibility differences, again here, in the ankle, and hip, and again here. You get the point, asymmetries at least play a part in motor control deficits. Asymmetries demonstrate an obvious motor control issue and should be addressed early on as to promote carryover to other fundamental movement patterns. Just yesterday we cleaned up an asymmetry in extension which after corrective exercises we saw a functional multisegmental flexion (which was previously DN).
Working from the top down is a convenient way to standardize treatment. It is intuitive due, in part, to the overlapping mobility and motor control requirements of the big 7. Correcting dysfunctional flexion requires motor skills that are intrinsic to the squat, etc. However, the piece that trumps the top down approach is the idea that the biggest dysfunction is targeted first (after asymmetries). This may occasionally cause conflict between clinicians, since the differences may be subtle, however, as mentioned before, this will have minimal effect on the final goal/outcome.
The beauty of the SFMA is that it allows clinicians to treat painful conditions without “chasing the pain”. In other words, due to the known relationships between pain and motor control, we are able to eliminate dysfunctional movement, which breaks the pain cycle, often eliminating pain without targeting the location of the pain. When necessary, specific pain generating tissues are addressed with appropriate, with manipulation and dry needling for example. When the model is followed appropriately it adds precision and standardization to treatment. I look forward to facilitating more discussion during future meetings.
