Why the SFMA (And Why First Impressions Should Not Be Your Diagnosis)
You will often hear the Functional Movement Systems team talk, and even emphasize, the importance of having a system in place to assess movement. A system allows an unbiased approach to look at the individual and form a plan of care for efficient results. One of my fellow SFMA instructors, Behnad Honarbakhsh, describes it perfectly:
Diagnostics should be black and white. Your treatment is where the art comes in.
How often do we make a judgment on an individual’s problem prior to completing an assessment based on their age, what we visually see, or on their sex? We are all probably guilty of making an educated guess and, perhaps, even treating based on that guess. I don’t have scientific research here, but I think it’s fair to assume that many times, our educated guess may be correct. But there is also a percentage of the time when our treatment does not work. So, we throw another technique at the individual’s problem, hoping this time we get it. Wouldn’t it be more effective, and time efficient, to stick with a repeatable system that guides us to the true reason the person is having a problem?
At a recent SFMA course where I was teaching, I had the pleasure of meeting Harrison and would like to share his story with you. Harrison volunteered to be my example for the SFMA’s Upper Extremity Pattern 2 breakout. Take a look at his movements:
Top Tier Patterns
Based on the SFMA Top Tier criteria, both left and right Upper Extremity Pattern 2’s would be classified as dysfunctional, non-painful (DN). One should be able to reach over their head and touch their fingers to the opposite shoulder blade.
We all probably start to make assumptions about what is stopping Harrison from reaching his hand over his head to reach his opposite shoulder. I certainly did! While I stood there watching his attempts, a couple of thoughts crossed my mind. But, what stood out to me was a significant lack of mobility affecting his bilateral movement, most likely in the thoracic spine.
Despite my initial subjective thoughts, I continued following the system and moved forward to the UE Pattern 2 breakout. That is where it got interesting. The first areas we assessed were unilateral thorax extension/rotation bilaterally using our Lumbar Locked Test.
Harrison struggled to complete the thorax extension/rotation movement on his own and demonstrated compensations bilaterally versus clean movement. Passive testing revealed full range of motion bilaterally, thus proving Harrison does have the ability to extend and rotate his thorax; he just isn’t able to do it himself. I just identified a bilateral Thorax extension/rotation stability/motor control dysfunction - not a mobility dysfunction! No one was more surprised by this finding than me
After watching Harrison’s top tier test, my first guess was thorax mobility restrictions. But, now that was off the table. Luckily, the system had me continue through the process of the breakout, moving to assess his shoulder and elbow movements into the whole pattern. Harrison was not able to complete the movement, and was I unable to do it for him.
Prone Active & Passive UE Pattern 2
Because I was not able to complete the full pattern functionally, I now had to assess the parts that make up UE Pattern 2 – Shoulder External Rotation, Shoulder Flexion/Abduction, and Elbow Flexion with the shoulder flexed. I looked at the left side first. As you’ll see in the video, Harrison was not able to complete the movements. However, I was able to do it for him, thus, identifying stability/motor control dysfunctions of all the parts.
Left Shoulder Pattern
My educated guess of mobility restriction, at least on the left side, was definitely not the case. Moving on to assess the right side, I found the same findings -- no mobility findings in any of the parts on either side!
Right Shoulder Pattern
Not only was I surprised, but Harrison was also shocked. We had determined that he had all the necessary motions needed to complete UE Pattern 2, but he could not coordinate the movements. I could easily take him into full range of motion for all the parts without restrictions or tension.
Had I seen Harrison in a clinical setting, I certainly would have collected a medical history. This history would have included a fractured left scapula, a fractured left clavicle and a fractured right second metacarpal from a mountain biking accident two years prior. The left clavicle did require a surgery to reduce it, including a plate with six pins to stabilize it. Surprisingly, his insurance did not approve physical therapy visits for these injuries.
It’s important to know this information, but would it have led me to believe Harrison had a mobility restriction and skip steps? Adopting SFMA into my practice years ago meant silencing my subjective thoughts to focus on the objective findings.
Continued conversation with Harrison revealed a positive loss of consciousness with this same biking accident. Could this be a contributing factor to his lack of motor control over these shoulder movements?
Since the accident, Harrison recognized there was a limitation, but believed it was a mobility problem, leading him to use mobility interventions (including spinal manipulations). Harrison’s response to these manipulations was always discomfort with no change to his shoulder movements. Let’s think through this for a moment: why weren’t mobility techniques working and why were they causing discomfort?
Based on his SFMA UE Pattern 2 findings, Harrison already had full range of motion and did not know how to control it. Giving him more mobility, on of top the range he already had and could not control, was creating more instability. He needed to learn, or remember how, to control the movement.
It is important to note that we had several conversations discussing the need for intervention on the head trauma issue. I also cautioned that proceeding to stability/motor control interventions could recreate head-related symptoms. However, Harrison wanted to move forward. At the course, I continued our assessment by moving to the Upper Extremity Prone to Supine Rolling patterns to determine the level of severity of the stability/motor control dysfunction, and, with the condition, we would stop if it provoked head-related symptoms. Prior to executing the rolling patterns, I did check his cervical patterns, which were also motor control dysfunction.
We found that was Harrison was not able to roll from prone to supine with upper extremity lead and he could barely lift his arm up off the ground. This identified a fundamental motor control dysfunction. After a few minutes of some specific motor control reprogramming work, Harrison shocked himself by rolling over and then standing up and completing Pattern 2! Look at this video taken two days post-course:
His pattern is not fully functional, but what a tremendous difference! With continued work, it will only improve, without a single mobility technique used.
Sticking to an objective system brought us to a proper diagnosis. With a proper diagnosis, an effective intervention was applied with immediate positive results. No time was wasted, and we had a very happy, and very surprised, patient.
Huge thanks to Harrison for allowing me to tell his story and for volunteering that day so we can all remind ourselves how important a system is. Harrison’s case, along with so many others, reinforces the philosophy: Don’t guess – assess.
Michele Desser is a Certified Athletic Trainer for the National Athletic Trainers Association. She comes from a strong background of injury prevention, rehabilitation, movement assessment and performance training. Her expertise in the areas of Junior’s, Movement Assessment and Correction, Strength Development, Speed Development and Golf Training allows her to help her clients achieve optimal mobility and stability patterns of movement. She has served as the training and movement assessment practitioner for the TPI Experience Team at the Titleist Performance Institute in Oceanside, CA. Michele received her Athletic Training education at the University at Buffalo.