reconsidering the way we look at movement...•always remember the map is not the territory! •when...
TRANSCRIPT
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Reconsidering The Way We Look at Movement
Gray Cook MSPT, OCS, CSCS Pitt-Marquette Challenge Lecture
Virginia Commonwealth University
February 1, 2012
Thanks for coming
How did I get here?
Too many smart people disagreed on movement topics like exercise,
rehabilitation and athletic performance. I realized it was a
question of perspective.
So I forced myself to look at movement differently!
Keys to Considering Movement
1. Never forget the developmental foundation
2. Consider patterns and parts equally
3. Screen, Test, Assess – Basic Function
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A little history for you…
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Keys to Considering Movement
1. Never forget the developmental foundation
2. Consider patterns and parts equally
3. Screen, Test, Assess – Basic Function
1. Never Forget The Developmental Foundation
Did you catch that?
1954
1965
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Is this a bad movement or have we just become bad squatters?
Argue for a cultural weakness and you will soon own it!
Keys to Considering Movement
1. Never forget the developmental foundation
2. Consider patterns and parts equally
3. Screen, Test, Assess – Basic Function
2. Consider Patterns and Parts Equally
Reductionism is necessary but not sufficient We are good at measuring specific points, but not as
consistent when measuring whole patterns.
We must develop a system for discussing movement patterns that fosters
communication and clarity among the many professions
that claim movement as their territory.
The Jump Study
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Jump Study – take away
• The movement pattern changed but no change in anatomical parts was necessary.
• Don’t ask for a positive adaptation if you cannot get a positive response.
• Most neurological systems are not operating as efficiently as they potentially can.
Movement Patterns
Is squatting deep normal or exceptional?
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Movement Patterns
When a squatting pattern is poor, is the reason always anatomical?
Be Practical in Your Practice
• Anatomy, Kinesiology, and Biomechanics are not
movement – they are simply ways to discuss parts and patterns of movement.
• Always remember the map is not the territory!
• When you are lost in the wilderness do you want a competent woodsman or a mapmaker?
Keys to Considering Movement
1. Never forget the developmental foundation
2. Consider patterns and parts equally
3. Screen, Test, Assess – Basic Function
3. Screen, Test, Assess – Basic Function
Professional Confidence? “Thin Slicing”
• The Book “Blink”
• Expertise - advanced pattern recognition
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“Thin Slicing”
Experts in any field are able to accurately and quickly identify patterns, while novices stumble through the process and do not recognize the salient features of things.
Goldman Algorithm
• ECG
• Unstable Angina
• Fluid in Lungs
• SBP <100 mmHg
– a 70% improvement in identifying
these patients (95% probability)
Please Define
• Screen
• Test
• Assess
Screen
1) A system for selecting suitable people…
2) To protect somebody from something
unpleasant or dangerous….
Practical Meaning – to check risk
Test
1) A series of questions, problems, or
practical tasks to gauge somebody’s
knowledge, experience or ability...
2) Measurement with no interpretation
needed
Practical Meaning - to measure ability
Assess
1) To examine something in order to
judge or evaluate it...
2) To calculate a value based on various
factors...
Practical Meaning – to judge inability
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Working Definition
• Screen – Rate and Rank Function
• Test – Measure Ability Function
• Assess - Inability / Dysfunction
Working Definition
• Screen – Predict
• Test – Predict
• Assess – Diagnose
Rate & Rank Problems… then measure!!!!!
Checklists?
Keys to Considering Movement
1. Never forget the developmental foundation
2. Consider patterns and parts equally
3. Screen, Test, Assess – Basic Function
We have a problem… It all starts with Function!
• Functional Training
• Functional Exercise
• Functional Rehabilitation
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What is Function?
Can you define function as it pertains to movement?
Defining Function
• Define dysfunction
• Function is the absence of dysfunction
Dysfunction
• Dysfunction =
limitations with movement competency
• Deficiency =
limitations with physical capacity
Dysfunction
• Movement competency below a standard accepted level
• The accepted level is based on:
– risk of injury
– poor adaptive capability
• Separate from physical capacity
But where should we start looking for dysfunction?
What movement parameter should we use?
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1. Never Forget the Developmental Foundation
How about movement patterns used in
fundamental development?
2. Consider Patterns and Parts Equally
Movement Patterns
“There are numerous ways in which slight subtleties in movement patterns contribute to specific muscle weaknesses...
Dr. Shirley Sahrmann
Movement Patterns
The relationship between altered movement patterns and specific muscle weaknesses requires that re-mediation addresses the changes to the movement pattern; the performance of strengthening exercises alone will not likely affect the timing and manner of recruitment during functional performance.”
Dr. Shirley Sahrmann
What is she talking about?
• Motor Control
• It’s a much better term then “stability”
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Considering Patterns of Movement
• During the 1990’s, the continued evolution of rehab required that movement remain the central focus.
• The APTA adopted a philosophical statement clearly stating that movement dysfunction is the basic problem addressed by rehab intervention.
Ok - we need to look at movement patterns – how?
We need a SOP! – standard operating procedure
– a consistent reproducible system
Stick to a System (standard sequence)
“Only by sticking to a standard sequence will the physician be sure of leaving nothing out and only by leaving nothing out are true findings feasible.”
Dr. James Cyriax
Consistency
“The physician arrives at a diagnosis not from the evidence furnished by one painful movement but by careful determination of a consistent pattern.”
Dr. James Cyriax
It seems clear
• We should look at movement patterns.
• We need a consistent system to address movement dysfunction.
• But what else can we do?
We can’t just talk movement and function; we also need
to consider pain!
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Questions
• Do people move poorly because they are in pain?
or
• Are people in pain because they move poorly?
What about pain?
“Pain, however undesirable, serves an important biological function acting as a warning signal that all is not well in the movement system.”
- Dr. Vladimir Janda
What is the problem?
“Nothing is ever one thing, but usually a complication of multiple factors with each hiding the others tracks...”
How will we group in the future? Screen, Test, then Assess
• Screen – Generalized Grouping of Dysfunction
– Asymptomatic (no report of pain with movement)
• Test – Specific Measurement of Dysfunction
– Asymptomatic (no report of pain with movement)
• Assess – Judgment of Dysfunction / Diagnosis
– Symptomatic (pain associated with movement)
Observe the order or lose perspective!
1. Squatting
2. Stepping
3. Lunging
4. Reaching
5. Leg raising
6. Push-up
7. Rotary Stability
THE FUNCTIONAL MOVEMENT SCREEN Scoring of the FMS
- Perform Pattern as Directed 3
2
1
0
- Perform Pattern with Compensation/Imperfection
- Unable to Perform Pattern
- Pain with Pattern Regardless of Quality
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Rate and Rank Movement Competency
Pain with movement – regardless of quality
Dysfunctional movement quality
Imperfect movement quality
Near perfect movement quality
Then measure the level of severity in the category
Grouping is the KEY!
Pain with movement – regardless of quality
Dysfunctional movement quality
Imperfect movement quality
Near perfect movement quality
Y – Balance Testing
• Cervical Patterns
• Upper Ext. Patterns
• Multi-Segmental Flexion
• Multi-Segmental Extension
• Multi-Segmental Rotation
• Single Leg Stance
• Squatting Pattern
Assessment “The Big 7”
- The Big 7
• Cervical Patterns
- The Big 7
• Upper Ext. Patterns
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- The Big 7
• Multi-Segmental Flexion
- The Big 7
• Multi-Segmental Extension
- The Big 7
• Multi-Segmental Rotation
- The Big 7
• Single Leg Stance
- The Big 7
• Squatting Pattern FN - Functional and Non-Painful
FP - Functional and Painful
DP - Dysfunctional and Painful
DN - Dysfunctional and Non-Painful
Scoring of the SFMA
Stop Treatment
Proceed with
Caution
Continue Treatment
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Where Does SFMA Fit In?
History
Ortho-Neuro Exam
SFMA
Local Biomechanical Testing
So What Do We Know?
Neurodevelopmental Perspective
Altered Motor Control
Regional Interdependence
Altered Motor Control
Pain with Movement
• Movement complicated with pain produces inconsistent and unpredictable movement patterns.
• Movementbook.com - Chapter 2 videos
Neurodevelopmental Perspective
Neuro-Developmental Perspective
The Neuro-Develomental Perspective has taught us that movement was developed in patterns not in individual muscles.
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This concept is more complete than stability training for many reasons!
• This concept is about control - not activation.
• Motor control involves coordination and balance of complementary muscular influence.
This concept is more complete than stability training for many reasons!
• Some muscles need to be turned up and some need to be turned down.
• The responses need to match the changes in the internal and external environment.
Neuro-Developmental Perspective
We knew any assessment had to be derived from basic patterns that are part of the natural development of human movement.
Regional Interdependence
Regional Interdependence
“Refers to the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint.”
-Wainner et al JOSPT 2007
The injury behind the injury
• Concussion! – Neck???
• Ankle! – Hip???
• Shoulder! – Wrist, Hand, and Elbow???
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Regional Interdependence
“A muscle may appear weak when it is not, if there is inadequate stabilization of its attachment points, which itself is dependent upon a chain of muscles.”
- P. Kolar
Mobility and Motor Control = Movement Pattern
•Hips
Mobile
•Core
Stable •T-Spine
Mobile
“Broken Pattern” (first identify – then measure)
•Hips
Stiff
•Core
Sloppy •T-Spine
Stiff
Lets Summarize
Point One
• Establish a SOP for identifying dysfunction within fundamental movement patterns
– Define dysfunction
– Agree on fundamental movement patterns
Point Two
• Separate painful movement patterns from dysfunctional movement patterns whenever possible.
• Use a reliable tool to compartmentalize problematic movement patterns
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Point Three
As a general rule do not manage or treat painful movement patterns with exercise.
– Manage painful movement patterns with manual therapies and modalities
– Manage dysfunctional movement patterns with systematic corrective exercise strategies and use manual efforts and modalities to assist as needed
Point Four
• Identify impairments within dysfunctional movement patterns
– Limitations in mobility
– Limitations in motor control
Point Five
Establish minimum levels of mobility followed by minimum levels of motor control competence whenever possible and retest the dysfunctional movement patterns
(Test / Retest Model)
If we don’t think logically about this stuff - who will?
“Make things as simple as possible… but no simpler.”
Albert Einstein
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FunctionalMovement.com The End