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Why Look at Movement?

January 10, 2019

Why Look at Movement?

Michael Voight PT, DHSc, OCS, SCS, ATC, CSCS, FAPTA

Alternating layers of stability, mobility, stability, mobility

If you don’t know an athlete’s movement capabilities, how can you be sure that they can physically do what you want them to do?You need to assess – don’t guess!

In most healthcare segments, i.e., eye, dental and heart, we use screens to see signs before symptoms are present. In musculoskeletal care, we wait for symptoms and then arbitrarily value the signs we think contribute to the problem.

The traditional model of medical education is an isolated approach to dealing with pathology. For example, if my knee hurts then I must have a knee problem. If my elbow hurts, I must have an elbow problem; however, the weak link in the chain is where the problem lies. The mistake we make is assuming that the source of the pain is also the cause of the pain, and in many cases the cause of the pain is at a distant site.

Think about the body as a whole. Everything's interrelated to one another. We call this “regional interdependence”, meaning one joint depends on other joints for how they work.

As an extension of the regional interdependence model, if you think about the major joint regions in the human body, they're designed to either be mobile or stable; and it’s interesting that these regions alternate. Let’s start at the hip, which is highly mobile as it moves in three planes. If I move directly above the hip, you have the lumbar pelvic region. That should be nice and stable. If I go to the next joint up, the thoracic spine region (cumulative 12 motion segments), it should be mobile. It allows our trunk to move and rotate. Next joint out is the scapula, or scapula thoracic articulation. That definitely needs to be stable. Next one out is the shoulder joint; that's highly mobile. Next one's the elbow; stable. Wrist; mobile. What if I drop down from the hip? Hip was mobile. Next thing down is the knee joint which needs to be stable. The knee is stable, but the hind foot is mobile to adapt to terrain when walking.

So, it’s alternating layers of stability, mobility, stability, mobility. Looking at movement is critical to treatment because of this regional independence. If the hip loses mobility, the body will always try to find a way to move resulting in an adjacent joint or region picking up the slack and moving more than it should. The body will compensate for the lack of mobility in one region.

With the athletes I see, one of the most common reasons for low back pain and dysfunction is loss of hip mobility. It's not intuitive that the hips are the problem because the hips don't hurt. But they don’t hurt because they're not doing anything; they're not moving. The lumbar spine has taken all the brunt of the force that normally would be attenuating through the hips.

Occasionally when I explain this stability and mobility model to someone dealing with low back pain and little hip mobility, they’ll ask, "Do you think that's why my knee is starting to hurt as well?" I say, "Yes, of course it is." Not only does the force being attenuated move, or is transferred from the lumbar spine, it's also being transferred down to the knee as well. The joints above and below are flipping. Remember, the knee is supposed to be stable, but if I'm forcing that movement from the hip at the knee, it starts to become somewhat unstable or have more force on it. I see all kinds of crazy things in athletes where patterns flip. But if we look at movement and total body movement first, as opposed to taking a myopic approach and just going right to where it hurts, we can identify potential causative factors of why the athlete is experiencing pain. I think not looking at total body movement is a common mistake in rehabilitation; and for athletic training, rehabilitation is a big thing.

It's alarming to me that the number one predictor of injury in the human body is previous injury. A lot of studies have validated this. But here's what I see: with injury, either something fundamentally changes in the body, which predisposed you to injury, or we're not doing a good job at rehabilitating people. I think the later happens because of our training. We're very good at myopically looking at the isolated joint where the problem is, we’re very good at getting rid of pain, and we're very good about strengthening muscles, but unless we look at movement and the big picture, we may never get to the actual cause of the problem. As soon as we let an athlete go back to play or a patient go back to work, there's a high likelihood that if we’ve not addressed the problem, over time that problem is going to come back.

I’ve learned that if you train the muscle you may not completely develop the movement, but if you train the movement the muscle will develop appropriately. Therefore, we need to look more closely at movement.

The SFMA offers a unique perspective for corrective exercise in a clinical setting.

So, let me get back to screening versus assessment. The Functional Movement Screen (FMS) identifies and classifies injury risk in a healthy population. The FMS data captures fundamental movements, motor control within movement patterns, and competence of basic movements uncomplicated by specific skills. By observing these movements, the screening will help to determine the greatest areas of movement deficiency, demonstrate limitations or asymmetries, and eventually correlate these with an outcome. Once you find the greatest asymmetry or deficiency, you can use measurements that are more precise if needed.

The FMS is a screen, not an assessment. Unlike the Selective Functional Movement Assessment (SFMA), the FMS does not have a formal breakout or built-in movement reduction for each pattern because it’s not a diagnostic system. The purpose is to set a movement baseline and identify major problems with basic movement patterns. Attempting isolated diagnosis would create an extra step without offering greater corrective solutions, and could even offer fewer options in some cases. Screens are meant to identify red flags and provide direction. If you are borderline hypertensive, your doctor tells you, “Eat healthier, make sure you’re exercising and schedule a check-up in 6 months”.The FMS is like taking blood pressure. If I take your blood pressure and it’s 150/90, I just found out that you’re hypertensive. I don’t know WHY you’re hypertensive. If your scores are through the roof or you don’t demonstrate improvement at follow-up, further assessment is needed. Likewise, if you score a 9/21 on your FMS, I just identified that you have some serious basic movement dysfunctions that are increasing your risk of injury. I haven’t identified WHAT is driving your dysfunction with certain patterns.

That’s where the SFMA comes in, which was developed as an extension of FMS and to look at movement when pain is present. The SFMA navigates the musculoskeletal assessment and is helpful during the initial patient examination, although some acute problems make it impractical at the outset. Outside of exposing dysfunctional regions that may complicate the examination process, the SFMA offers a unique perspective for corrective exercise in a clinical setting. We begin the SFMA with seven top-tier assessments. These tests are used to determine the breakouts we use to separate pain and dysfunction when possible, and will help identify movement patterns where exercise is indicated or contraindicated.

In summary, SFMA focuses on finding the root and cause of symptoms by breaking down dysfunctional patterns logically rather than simply finding the source of the pain. An isolated or regional approach to evaluation and treatment will not restore complete function. When the clinical assessment is initiated from the perspective of a movement pattern, the healthcare provider has the opportunity to identify meaningful impairments that may be seemingly unrelated to the main musculoskeletal complaint, but contributes to the associated disability.

In 2019, I will again be leading Selective Functional Movement Assessment (SFMA) continuing education courses throughout North America. Course participation fulfills 16 hours of Evidence Based Practice CEU’s for Athletic Trainers from the NATABOC. If you or your facility is interested in hosting a course, please contact us at https://www.rehabeducation.com/contact/.I know that maintaining or restoring precise movement of specific segments is the key to preventing or correcting musculoskeletal dysfunction.

Remember, when challenged, the human body will always sacrifice quality over quantity of movement. It will migrate toward predictable patterns of movement in response to injury or in the presence of weakness, tightness or structural abnormality. When the movements are altered, or strength and flexibility are compromised, negative changes occur in the musculoskeletal system. This will eventually lead to injury of these tissues and pain will result.

Bio - Dr. Michael Voight teaches at the Belmont University Physical Therapy Program in Nashville Tennessee. He remains extremely active in patient care, education, and research activities, and his lectures are both well attended and receive excellent reviews based upon his innovative presentation of the scientific evidence and the interactive fun approach to teaching.