After wiping the tears and coming to the stark realization of our (ir)relevance in performance, we must ask where do we fit in? Do we matter?
I’ve asked myself this question many times. It is hard to answer when tactical over-utilization begets repetitive stress injuries; a poor night’s sleep, Slurpies, and donuts make someone ill; or a contact play ends a career. What could I have done differently? What was my role?
Though these questions have required skill development in special physical preparedness, sports science, and stress management; improving general qualities is pertinent in certain scenarios. It is these times in which rehab and training is of utmost importance, and we regain our relevance.
This is a chapter 7 summary of the book “Movement” by Gray Cook.
The SFMA’s goal is to assess functional capabilities. This system is based on Cyriax differentiation and grading principles. Instead of describing things as strong, weak, painful, or painless; the following descriptors are utilized:
Functional nonpainful (FN): Unlimited movement and able to complete a breath cycle at end-range. Called the dead end.
Functional painful (FP): Called the marker, reassessed.
Dysfunctional nonpainful (DN): Limited, restricted, impaired mobility, stability, or symmetry. Labored breathing with movement also implicates this choice. Called the pathway, where treatment occurs.
Dysfunctional painful (DP): Called the logical beehive because we do not know if pain is causing poor movement or vice versa. It is an unreliable place to work unless acute situations.
SFMA corrective and manual therapy lie in treating the FP’s and DN’s. The order at which things are treated also matters, so the order listed below for the top tier tests is also typically where treatments should hierarchically begin.
Cervical spine patterns (CSP)
Upper extremity patterns (UEP)
Multi-segmental flexion (MSF)
Multi-segmental extension (MSE)
Multi-segmental rotation (MSR)
Single leg stance (SLS)
Overhead deep squat (ODS)
We then operate the SFMA in the following fashion:
Ideally, the FMS would be part of the basic tests performed when one is looking to participate in sport. Prior to any athletic engagement, a medical exam is performed to clear someone to participate. This exam is often followed by performance and skills tests. Gray feels that the FMS belongs between these two tests, as there is an obvious gap from basic medical screening to high performance.
It is not to say that we must only train movement patterns. Rather, all the above qualities can be trained in parallel. The real goal is to manage minimums at each level and make sure improving one does not sacrifice quality at the others.
This is a chapter 3 summary of the book “Movement” by Gray Cook.
You Down with SOP?
Unlike many other areas, movement does not have a standard operating procedure and is thus very subjective. Since movement is the foundation for all activity, it is important that we develop some type of standard for good movement.
Movement compensations are often unconscious, thereby making these patterns difficult to be cued away. It may be the case that less threatening movements and corrective exercise could be utilized to change undesired patterns.
When designing exercise, it is important to make them challenging as opposed to difficult. Difficulty implies struggling, whereas challenges are what test one’s abilities. Anyone can make something difficult, but not all can challenge.
Function of the FMS and SFMA
The goals of the functional movement systems are as follows:
1) Demonstrate if movement patterns produce pain within accepted ranges of movement.
2) Identify those without pain that are at high injury risk.
3) Identify specific exercises and activities to avoid until achieving the required movement competency.
4) Identify the best corrective exercise to restore movement competency.
5) Create a baseline of standardized movement patterns for future reference.
The difference between the FMS and SFMA is that the FMS assesses risk whereas the SFMA diagnoses movement problems.
The FMS operates in the following manner:
1) Rates and ranks nonpainful movements based on limits and asymmetries.
While much of talk in rehab deals with tissue injury and tissue pain, realize that the brain always makes the final decision as to whether or not you should feel pain. No brain, no pain.
This sentiment does not mean that pain is not real. All pain is real. However, pain is a construct that the brain creates in order to ensure your survival.
Spinal Cord Alarms
When an injury occurs and the DRG receives impulses from peripheral structures or the brain, the spinal cord neurons must adapt to better uptake all these signals. In essence, the DRG becomes better at sending danger messages up to the brain. This change leads to short term increases in sensitivity to excitatory chemicals. Those stimuli that didn’t hurt before now do (allodynia) and those that used to hurt now hurt more (hyperalgesia).
In persistent pain, this change continues occurring to the point where neurons that do not carry danger messages start growing into space where danger messages are taking place. Now innocuous stimuli such as grazing the skin begin hurting. The pain may be normal, but the underlying processes become abnormal.
When these spinal cord alarm systems become unhealthy, the brain no longer receives an accurate message of what is going on. The alarms become magnified and distorted. The brain is told there is more damage in the tissues than is actually present.
What is good is that this increased sensitivity can change once damaged structures are under control and/or the underlying physiological processes are understood by the person in pain.
Another change that happens in the brain is termed smudging, in which brain areas devoted to body parts or functions begin overlapping. This process is why some body parts may become difficult to use or other areas become sensitive compared to the injured area.
Fortunately, since the brain homunculus frequently changes, these effects are reversible. The homunculus must be trained just like any other muscle or skill.
It is now understood that thoughts are powerful enough to maintain a pain state, known as thought viruses. These viruses are known to cause and enhance a low back pain experience, and likely have an effect at the whole body. Here are some examples of thought viruses.
Pain means something harmful is happening to my body.
Stopping social activity because of pain.
It is bad if no one can find out what is wrong with me.
Pain scares me.
Refusing to move until all pain is gone.
Central Sensitization is when the brain and spinal cord become overly sensitive to processes. This change occurs in chronic pain states. Diagnoses such as fibromyalgia, chronic fatigue syndrome, and non-specific low back pain are often given out. The diagnosis given often depends on where you live and which health professional you have seen. Here are the characteristics of central sensitization.
Pain persists past normal healing times.
Pain is worsening.
Lots of movements hurt. Even imagining movement can hurt.
Pain becomes unpredictable.
There are other past, present, and future problems in life.
The Autonomic Nervous System
The sympathetic nervous system helps us cope and stay protected from threat. It does so by sending adrenaline to all the tissues among many other processes.
In chronic pain states, there are increased levels of adrenaline, though in some cases adrenaline can become depleted. Adrenaline does not itself cause pain, but does increase alarm system sensitivity.
On the other hand, the parasympathetic nervous system is what slows us down and helps shift us out of a sympathetic state. This system is why relaxation and meditation can help with the healing process.
The Endocrine System
Chronic pain states are often associated with high levels are cortisol as well. Cortisol often gets a bad rap despite its role as a protector. What cortisol does is slow down unnecessary body processes which are not needed for immediate protection and enhances those which are.
The Immune System
The immune system has a major link to the autonomic and endocrine systems. The immune system works by releasing pro-inflammatory cytokines, which can create lethargy, loss of appetite, sensitive movements, etc. Even old pains can come back because of cytokines. Here are some fun immune system facts.
Immune system becomes more involved in serious or chronic states.
Immune system responses can become learnt.
Long-term stress and pain can lead to altered activity which leads to more cytokine production.
Immune stressors can be major or multiple minor events.
The immune system may underpin pain states such as mirror pain and loss of fine sensibility.
The immune system can be activated by the brain.
There are also several ways you can boost your immune system to counteract pain causing behaviors.
In threatening states, big mover muscles become primed. This change occurs evolutionarily so your body can escape potential threats. In injured states, prime movers can act as splints. If this state occurs for the long term, muscles can start to feel stiff and achy. Even if pain is gone, sometimes these muscles do not return to their normal activity levels.
This is a summary of section 2 of “Explain Pain” by David Butler and Lorimer Moseley.
Tissue Injury 101
When a body is damaged, pain is often the best guide to promote optimal healing. Sometimes it is good for us to rest, other times it is better to move.
A similar healing process occurs for all tissue injuries. First, inflammation floods the injured area with immune and rebuilding cells. This reason is why inflammation is a good thing in early injury stages.
A scar forms once the inflammatory process is over. The tissue then remodels to attempt to become as good as the original. Blood supply and tissue requirements determine how fast the healing process occurs. For example, ligaments heal much slower than skin because the former has a lower blood supply than the latter. This may also be a reason why aerobic exercise may speed up the healing process.
If present, pain usually diminishes as the tissues heal. However, pain may persist if the nervous system still feels under threat.
Acid and Inflammation
The alarm sensors described here constantly work and often get us to move. Movement keeps our system flushed. When we don’t move or a physical obstruction is present (e.g. sitting), acid and by-products build up in the body tissues. Oftentimes we will start to feel aches and pains when we stay in a prolonged position, which is our body’s way of saying “get up and move.”
Much like the alarm system, inflammation is a primitive way for our body to continue the healing process. Inflammation is designed to hurt so the injured area has time to heal. There is no need to fret when swelling, redness, and pain are present; our internal systems are merely repairing us.
We call swelling and its corresponding cells the “inflammatory soup.” This soup is a by-product of blood and chemical transportation, and sets off our body’s alarm system to increase sensitivity. All of these changes are essential to facilitating a healing environment.
Everybody be hatin’ on muscles nowadays as the source of our aches and pains. However, the authors put muscles in perspective for us with the following points.
Muscles are loaded with sensors, so can impact the pain experience.
Muscles can become unhealthy and weak.
Muscles are very difficult to injure, they are just very responsive structures.
Muscles are well vascularized which allows for quick healing.
The reason the authors wish to change the name of these structures is because anatomically they do not resemble a disk at all. The new name is “living adaptable force transducers,” or LAFTs.
LAFTs are made up of the same material as your ear, and contain some very strong ligaments. In the medical world, we have many different treatment modalities that target the LAFT. We have McKenzie, traction, surgery, and injection to name a few. Because there are so many different treatments for these structures, it is fair to say that LAFT injuries are still not fully understood.
LAFTs also come with very strong language: slipped, bulging, herniated. Using such strong language can stop someone from moving, which is far from the ideal regarding low back pain.
Here are some LAFT facts.
The LAFT outer layer has a nerve supply, so danger sensors can become activated easily. If the LAFT becomes injured, the surrounding structures will likely set off danger sensors as well. You want a lot of danger sensors if something is occurring near the spinal cord. It is kind of a big deal.
LAFT injuries usually do not cause instant pain. Pain usually occurs 8-12 hours later.
LAFTs naturally degenerate and do not have to contribute to a pain experience. At least 30% (and potentially up to 80%) of people without low back pain have LAFTs bulging.
LAFTs never slip.
LAFTs heal slowly, but they will always be a bit tatty around the edges. This attribute makes it hard to distinguish aging from injury.
LAFTs, spinal joints, and nerves are built to withstand high forces.
Skin and Soft Tissues
Our knowledge of pain is based predominantly on the skin. The skin mirrors the nervous system’s state. Rarely is the case that skin injury leads to chronic pain however. On the flipside, painful skin zones; changes in skin health; and altered sweating or hair growth can all be indicators of damaged nerves.
How often have you seen or had your skin become increasingly sensitive to touch after an injury? This is a common phenomenon that occurs because cutaneous nerves increase sensitivity in order to protect an injured area. Here are some other skin and soft tissue facts.
Damaged skin heals very quickly.
Skin has a high danger sensor density.
Skin is very mobile and loves movement.
Fascia is a strong tissue that lies under the skin and also contains many danger sensors.
Massage moves tissues and sends impulses to the brain. Therefore, movement and touch are great ways to refresh the virtual and actual body.
Bones and Joints
Most joints have lining known as synovium which keeps the joint contained and lubricated. This lining is loaded with danger sensors. Here are some other facts.
Joint pain seems to be dependent at which the speed damage occurs. Slow changes usually do not make the brain think there is danger. A dislocation however may lead to severe pain. Most people with worn joints never know about it.
Everyone has worn joints as we age. They are the wrinkles on the inside.
Joints love movement and compression.
Broken bones heal and are often stronger than before.
Joints in the back and neck can get injured, but may be too small to see on imaging. This may or may not set off the alarm bells.
Most of today’s neuroscientists agree that peripheral nerve problems are far more common than we think. Here are some fun facts regarding nerves.
Nerves have danger sensors.
Neurons can contribute to pain.
If a nerve becomes injured, it may become more sensitive to ensure you survive.
Nerves slide as we move. If a nerve cannot slide well, pain may occur while moving.
Nerves change as we age, just like everything else in our bodies.
Scans and nerve conduction tests cannot easily identify a damaged nerve.
Nerves can be injured but may not create a danger message for days to weeks.
The Dorsal Root Ganglion (DRG)
The DRG is like the brain of the peripheral nervous system. This is the first place that tissue messages are evaluated. Here are some facts for DRGs
Peripheral nerves have their nucleus in the DRG. It is here that sensors are made.
The DRG is extremely sensitive and changeable.
The DRG is very sensitive to blood chemicals, especially stress chemicals.
Sometimes the DRG fires just because. It is like your body’s car alarm. Sometimes the DRG can be hurt without having any pain too.
When a nerve is injured, oftentimes it will backfire. The reason for this is like a domino effect. If a nerve is stimulated at one end, it will send messages up the system to go to the other end.
Backfiring may not be an issue for the short term, but its persistence can lead to sustained inflammation. A less sensitive nervous system may lessen the amount of inflammation in the tissues.
Here are the common symptoms associated with peripheral nerve pain.
Movement or a sustained posture may ignite an injured nerve which keeps ringing.
May not hurt for a few days or weeks.
Skin zones may become itchy.
Might just feel weird.
Just because you feel these symptoms does not mean it is the end of the world. Understand that nerves are just responding to signals from the brain that tell them to increase sensitivity and improve warning capacity.
For today’s chapter, I have decided that the best way to learn these tests is to show you. I will write in any pertinent details you need for a good test performance.
The Straight Leg Raise (SLR)
Add sensitizers (dorsiflexion, plantarflexion, etc) to determine nervous system involvement.
Add cervical flexion or visual input to enhance responses.
Be mindful of symptoms before and after pain responses.
If this test is positive post-operation, it will likely be inflammatory in nature.
You can preload the system further with cervical flexion or sidebending the trunk away from the test side.
Here are some other ways to perform the SLR with sensitizers first. (I apologize for the way the camera shot in advance).
For tibial nerve-bias.
For fibular nerve bias.
For sural nerve bias.
Passive Neck Flexion (PNF)
Here is how to perform the test.
Add SLR to further bias the test.
Be mindful of Lhermitte’s sign, which is an electric shock down the arms or spine. This is a must-refer sign as there is potential spinal cord damage.
Here is how to perform the slump.
Slump Knee Bend
In the book itself, Butler uses the prone knee bend as his base test. However, NOI does not teach this motion as much and now favors the slump knee bend. This movement allows for much more differentiation to be had.
And the saphenous nerve (just so you get a break from seeing me).
Have some fun with these tests, and be mindful that you are not too aggressive.
Palpation is a major component to therapeutic touch, and gives us a way to build rapport and interact with our patients. When palpating the nervous system, it is important to palpate in sensitive positions so the nervous system is placed on load. Here are some general nerve anatomical rules.
Where a nerve has fewer fascicles and less connective tissue, palpation will be more sensitive (ulnar nerve).
Where there is a lot of connective tissue, there will be a more localized and less “nervy” response.
Where there is increased sensitivity does not mean there is damage locally. Damage could have occurred more proximally (that whole nerves fire in both directions thing).
You must also be mindful that anatomical variations are common, especially if symptoms seem anatomically weird. Here are some of the more common ones:
Martin-Gruber anastomosis: Median and ulnar communicate distally.
Rieche-Cannieu anastomosis: Deep branch of ulnar and recurrent branch of median nerve.
Absent musculocutaneous nerve.
Here are some basic nervous system palpation guidelines.
Nerves feel hard and slippery.
Palpate with your finger tip or thumb, and follow it proximally or distally.