This is a chapter 14 summary of the book “Movement” by Gray Cook.
Corrective exercise is focused on providing input to the nervous system. We are allowing the patients and clients to experience the actual predicament that lies beneath the surface of their movement pattern problem. It is okay for mistakes to be made, for these errors help accelerate motor learning. Minimal cueing should be utilized, as we want to patient to let them feel the enriching sensory experience.
Motor Program Retraining
There are several different methods in which we can achieve a desired motor output.
1) Reverse patterning – Performing a movement from the opposite direction.
2) Reactive neuromuscular training – Exaggerating mistakes so the patient/client overcorrects. Use oscillations first, followed by steady resistance.
3) Conscious Loading – Using load to hit the reset button for sequence and timing.
4) Resisted exercise – Makes patterns more stable and durable.
When you can deadlift that much, most anything is stable and durable.
This is a chapter 13 summary of the book “Movement” by Gray Cook.
Back to the Basics
Mobility deficits ought to be the first impairment corrected. Optimizing mobility creates potential for new sensory input and motor adaptation, but does not guarantee quality movement. This is where stability training comes in. In order for the brain to create stability in a region, the following ought to be present:
Structural stability: Pain-free structures without significant damage, deficiency, or deformity.
Sensory integrity: Uncompromised reception/integration of sensory input.
Motor integrity: Uncompromised activation/reinforcement of motor output.
Freedom of movement: Perform in functional range and achieve end-range.
There are 3 ways to gain mobility:
1) Passively: Self-static stretching with good breathing; manual passive mobilization.
2) Actively: Dynamic stretching, PNF.
3) Assistive: Helping with quality or quantity, aquatics, resistance.
In order to own our new mobility, we use various stability progressions to cement the new patterns. There are three tiers in which stability is trained:
1) Fundamental stability – Basic motor control, often in early postures such as supine, prone, or rolling.
2) Static stability – done when rolling is okay but stability is compromised in more advanced postures.
3) Dynamic stability – Advanced movement.
We progress in these stability frames from easy to further difficult challenges.
Assisted → active → reactive-facilitation/perturbations
Since stability is a subconscious process, we utilize postures that can challenge this ability while achieving desired motor behavior. We can also group the various postural progressions into 3 categories:
1) Fundamental – Supine, prone, rolling (requires unrestricted mobility).
2) Transitional – Postures between supine and standing such as prone on elbows, quadruped, sitting, kneeling, half-kneeling.
3) Functional: Standing variations to include symmetrical and asymmetrical stance, single leg stance.
This is a chapter 12 summary of the book “Movement” by Gray Cook.
A Whole Lotta P
When we build our corrective framework, we must take into account the 6 P’s:
1) Pain – Is there pain with movement? Staying away from pain improves motor control.
2) Purpose – What movement pattern are we targeting with corrective exercise and what problem are we addressing (i.e. mobility, stability, dynamic motor control)?
3) Posture – Which moderately challenging posture is the best starting point for corrective exercise that allows for reflexive activity?
4) Position – Which ones demonstration mobility/stability problems and compensatory behaviors?
5) Pattern – How is the dysfunctional movement pattern affected by corrective exercise?
6) Plan – How can you design a plan based on findings?
The goal when designing the correction is to stay in the middle ground of the autonomic nervous system while providing a rich sensory experience. Movement pattern dysfunction is a behavior that needs to be addressed and changed.
This is a chapter 11 summary of the book “Movement” by Gray Cook.
All exercise affects tone and tension. This influence is the basis for movement. The autonomic nervous system determines movement as threatening or not, which determines requisite tone. It is important to nudge movement towards further nonthreatening yet advanced stimuli.
Proceeding to correct under FMS protocol is determined by screen results and changed via exercise. We first correct mobility, next reinforce stability, then retrain movement patterns. Stability training in particular follows a sequence:
1) Challenge posture and position.
2) Build mid-range strength.
3) Develop end-range stability.
Movement patterns are corrected in the following hierarchy:
The SFMA corrective pathway is nonlinear unlike the FMS. The breakouts will tell you which direction to go to restore optimal movement.
The options are also increased. Often to gain mobility, you would utilize various manual therapies or other modalities. To alter stability, taping, orthotics, braces, or anything else to increase motor control may be utilized.
Movement patterns are corrected in the following hierarchy:
This is a chapter 10 summary of the book “Movement” by Gray Cook.
Mistakes, I’ve Made a Few
When we are talking corrective exercise design, people often make 4 mistakes:
1) Protocol approach: Exercise based on category.
Problem – 1 size fits all.
2) Basic kinesiology: Target prime movers and some stabilizers.
Problem – fails on timing, motor control, stability, and movement.
3) Appearance of functional approach – Use bands and resistance during functional training.
Problem – If the pattern is poor, adding challenges to it can increase compensation. There is also no pre-post testing.
4) Prehabilitation approach – Prepackaged rehab exercises into conditioning programs as preventative measures to reduce injury risk.
Problem – Design is based on injuries common to particular activities as opposed to movement risk factors.
There are also certain mistakes that are often made when utilizing the FMS and SFMA:
1) Converting movement dysfunction into singular anatomical problems.
2) Obsessing over perfection in each test instead of identifying the most significant limitation/asymmetry.
3) Linking corrective solutions to movement problems prematurely.
The overarching rule is to address these movement deficiencies first, as we do not want to put strength or fitness on top of dysfunctional movement.
The Performance Pyramid
When designing an exercise program, we look for three areas to improve performance: Movement, performance, and skill.
It is important that program design is based on the individual’s needs and has these qualities in a hierarchal fashion. For example, if one performs excellent on functional performance capabilities but has poor foundational movement, injury risk may increase.
When implementing corrective exercise, it is important to provide the correct stimulus amount. We want the individual challenged, but not struggling for dear life.
Too easy – >30 reps with good quality.
Challenging, but possible – 8-15 reps with good quality and no stress breathing. There is a decline in quality secondary to fatigue towards the end of rep ranges.
Too difficult – Sloppy from the beginning and only worsens.
Rarely does increasing difficulty equate to increasing resistance. Oftentimes you may advance the exercise position, decrease the base of support, or add more movement complexity.
You may have to remove some activities that feed into dysfunction from one’s current programming, lest you wish to not change the movement pattern. Often how quickly one changes his or her ability to move depends on how diligent one is with corrective exercise.
Realize that corrective exercise should only be supplemental and temporary to what one is doing. It is supposed to be corrective in nature, not preventative. Moreover, movement scores can decrease with hard training, so continual reassessment is important.
The corrective exercise pathway should proceed as follows:
1) Exercise selection is driven by screen and assessment.
2) A thought out framework gives you the best possible choices.
3) Retest, note positive or negative changes, and then use results to modify next session.
4) Reassess once an obvious change is noted to see what the next priority is.
This is a chapter 9 summary of the book “Movement” by Gray Cook.
While I have broken up these sections into patterns, much of what Gray talks about does not involve the patterns themselves, but are still good points to know. Ergo, much like the book itself, this post may seem a little disjointed 🙂
The Deep Squat
One’s inability to squat is not considered a single problem. Instead, a disconnect is present between the body and the brain in the squatting pattern. Our brain sees things in patterns, and the squatting pattern essentially gets smudged. Before performing the squat as an exercise, we must first groove an optimal movement pattern.
One interesting point regarding the squat is that as an exercise it is often a top-down based movement. However, when we learn to squat in development, the movement occurs bottom-up. So one way to train the squat is by starting from the bottom of the squat and working to standing. This method ensures full mobility to perform a full deep squat.
To relate the SFMA to the squat pattern, Gray is very clear about not training the squat if one cannot touch his or her toes.
Hurdle Step and Single Leg Stance
These two movements simultaneously test mobility and stability of both legs. Oftentimes in these patterns you will see a high-threshold strategy (HTS), in which a hyper-protective core response occurs. Research demonstrates that this stabilization strategy can cause poor motor control to occur. These tests also are basic precursors for stepping, running, and climbing.
In this section Gray also mentions that he does not recommend assessing static postures; namely because posture is dynamic and changing.
The inline lunge is more a test of control and efficiency as opposed to strength. Because we talk about control, we must discuss stability. It is important to note that stabilizers do not necessarily need to be strengthened, as these muscles will never be able to overpower prime movers. Instead, these muscles should be trained for endurance, timing, or quicker action.
Shoulder Mobility Reaching Test
These tests assess reciprocal arm patterns and thoracic spine mobility. The movement is challenging because opposing movements end up borrowing mobility and stability from other segments, thus potentially impairing these qualities.
Thoracic extension is necessary to perform this pattern. However, oftentimes people will compensate with thoracic flexion. This compensatory pattern can rob the scapulae of ground to help stabilize the movement.
Active Straight Leg Raise
There are several necessary components to perform this movement optimally:
Adequate mobility and flexibility of the elevated leg.
Pelvic stability prior to and during the movement.
Another interesting tidbit from this section was that research has demonstrated that one’s ability to perform a sit and reach correlated with arterial flexibility.
The pushup, rotary stability, and rolling patterns all assess core functioning. In particular, the pushup looks at reflexive core action, rotary unilateral and diagonal patterns, and rolling the ability to separate upper and lower quadrants.
These issues are also known as stability or motor control dysfunction (SMCD). Most conventional therapies would treat these complaints by strengthening the stabilizers, but this is problematic. When something works reflexively, how can we train something volitionally and expect changes? To train these muscles we must focus on proprioceptive and timing-based training.
Prime mover or global muscle compensation behavior or asymmetry.
Poor static stability, alignment, postural control, asymmetry, and structural integrity.
Poor dynamic stability, alignment, postural control, asymmetry, and structural integrity.
Mobility and stability can influence one another. If I were to lose mobility at one segment, motor control can be distorted at nearby segments. Conversely, if I lack motor control, abnormal mobility may occur to compensate. However, the progression remains the same—restore mobility, then improve stability.
Though the following testing protocols did not make the SFMA, they should still be tested per Gray:
Over the past few weeks I have felt called to write about an often uncovered yet extremely important component of the therapeutic process: Patient interaction.
We had an instance in which I came back into the clinic from my lunch break and my intern was supposed to have a patient evaluation. Instead, she opted to have me take this particular patient. This patient was a lovely 17 year old lady who was being seen for bilateral foot pain. This was her second bout of therapy, and her and her mother was very dissatisfied with their last physical therapy experience just a few months (and 17 visits) prior. She was not a happy camper and wanted a second opinion. After hearing stories from my coworkers, I expected the worst.
We progress through the evaluation, and my student observes nothing but smiles throughout from the patient and her mom. Jokes were cracked, movement was looked at, and edumacation happened. At this point, after a little explain pain and kinetic chain discussion, these women were sold.
We leave the treatment room and I said “that wasn’t so bad yes?” My student replies “that’s because they are in love with you.”
But really, that essentially is what you have to do with the patient interaction. You can have the greatest hands, the greatest exercise plan, and evidence up the wazoo; but if your patient hates your guts you will fail. I heard this from Patrick Ward that 80% of your success with patients depends on if they like you. A recent RCT supports this notion as well. You have to get your patient to fall in love with you and your approach, in a nonsexual manner of course.
While I am neither aware nor sure if possible there exists any evidence regarding the best way to interact with a patient, I am going to run through how I approach the patient experience. I don’t know if my way is the most successful or even the best way, but I generally get good patient satisfaction reviews so deal with it.
Here is what an excellent patient interaction achieves:
If you read The Polyvagal Theory, Stephen Porges discusses neuroception, which is basically how your nervous system responds to situations after evaluating all given sensory input. If your autonomic nervous system perceives someone or something as threatening you will either fight, flight, or freeze. The goal then, is to make the patient feel safe when working with you. This shift allows for decreased sympathetic response and increased prosocial behavior, both necessary and influential when working with pain states.
The patient interaction is also a great way to get the placebo effect. I know the placebo effect often is thought of as deceitful and providing ineffective treatment, but that is far from the truth. All the placebo effect does is maximize the belief and perception that a treatment will work. In fact, the belief that something will work is part of a recent CPR developed for cervical spine manipulation in neck pain. In On Intelligence, perception and behavior are one and the same. So by optimizing one’s perception, we can optimize one’s motor behaviors.
Moreover, I think it is important to have fun with what you do, and make the physical therapy experience a pleasant and rewarding time for all involved. Think of how we are perceived; “PT stands for pain and torture,” or “I hate physical therapy.” Adding humor and performing fun activities can make PT a more fruitful time.
Seeing how my student has been progressing is a good example of this. When she first started out, much of the focus was geared toward getting all the relevant information, making sure she was performing all the tests, manual therapy, and exercises well. One thing that was really lacking was the patient interaction. After stepping in a few times when she struggled, you could see some of her patients just open up and smile during our short stint together. After explaining the above to her, my intern is now asking patients about their life stories, weekend plans, and empathizing with their problems. She is even stealing some of my jokes, which is okay because half of my material is not original.
The first impression is very meaningful and sets the tone for the patient interaction. When I meet a patient for the first time, I will call them by name and have them walk to me. I get several pieces of information from this introduction:
1) Their sitting posture.
2) Their facial expression when you make eye contact.
3) How they get out of the chair.
4) Their gait pattern and speed.
These pieces help me understand how well and willing the patient moves, as well as their general demeanor. Depending on if I see someone hop right up with a huge smile on their face versus someone who is slouched in their seat and slowly trudges over towards me, my interaction with them often changes. With the former, I will be more upbeat, with the latter, I will be mellow. The more you can mirror the patient, the greater bond you can develop.
This small gesture reveals so much about your patient. The firmness and way they shake your hand can tell you a lot about their personality. There are several different handshakes you may experience:
Which you should use depends on how you wish to be perceived. If I see someone who seems to need more guidance, I may use a more dominant type of handshake. If I see someone who needs reassurance, I may use a more submissive handshake. Regardless of how you shake one’s hand, make sure you use firm pressure and warm eye contact.
The subjective examination is very important, but not for the reasons you think. I know my mentors in my residency will kill me, but I personally do not feel the subjective examination really steers me in a particular treatment direction. Rather, I see the following as the subjective exam’s goals:
1) Find out how you may help them.
2) Establish rapport.
3) Understand the patient and their story.
4) Make the patient feel understood.
5) Rule out red flags.
You obviously want to find out what brings them to you, but for me the objective tells me where to go. The subjective examination is more for the patient than you, so let’s talk about how to maximize that interaction.
How you face the patient can make or break your interaction. Remember the goal is to reduce threat perception and make them feel comfortable with you. To maximize this goal, you want to eliminate as many barriers as possible. So you probably do not want to face the patient like this…
And definitely not this
Rather, I like this orientation
Here you are staying close to the patient while simultaneously respecting their privacy because you are not directly facing them.
Now I know what you are saying, “But Zac, you are using a computer, clearly that is going to kill rapport and act as a barrier.” I would agree to some extent, there are two things here that you ought to notice:
1) The computer is not directly in front of the patient, thus is not a barrier.
2) I maintain quite a bit of eye contact while typing.
Now granted some people may still feel uneasy about me typing in front of them, so I will usually ask if I sense that this is problematic. But you can still develop some semblance of intimacy with the patient by playing with 5 different variables.
The 5 Intimacy Variables
In order to develop an intimate experience with the patient, we can add/subtract 5 different ways to create a bond with someone:
2) Eye contact
5) Saying the person’s name
The more of the above variables you utilize when you interact with someone, the more of an intimate encounter you may experience. You want to use neither too many nor too few variables when interacting with someone. Too many will make you seem creepy (and potentially send the wrong message) and too few will make you seem distant. I generally shoot for 2-3 at a time.
So if we take the above setup example, I am keeping a close proximity toward the patient and maintaining eye contact, however I am not directly facing the patient. I may modulate the interaction throughout by saying the patient’s name or providing a light touch of the arm. So here I can utilize my 2-3 variables at a time.
While the objective’s goal is to guide your treatment plan, it can also be a great time to further build rapport. Perhaps the best way to establish that you care is by providing a thorough examination.
How many people have been to a 5 minute physician visits compared to one who may spend up to 30 minutes taking a look at you? Which physician is better liked? The fact of the matter is, people want and expect a thorough examination, so give it to them.
This is where I feel like something such as the SFMA can come in handy. People may have gone to other clinicians who just looked at the affected region, but this clinician is looking at everything, he/she must be different. So when I am performing an assessment, I generally perform something closer to the SFMA top tier and then do my own type of breakouts from that. What can I say, I’m a rebel.
Throughout the examination, I will sprinkle compliments or ask about things like their plans for the rest of the day, anything I can do to further establish rapport.
So you finished the subjective and objective, and you likely have the information that you need to treat. The post-evaluation education is the spot in which you can really win or lose people. David Butler suggests that there four questions that the patient would like answered:
1) What is wrong with me?
2) How long will it take to get better?
3) What can I do to make it better?
4) What can you do to make it better?
I will usually educate the patients to some degree on pain physiology, followed by whatever objective impairments I find that can improve upon one’s complaints. In order to maintain low threat perception, I will rarely break out models or use terms such as “motion x is crushing body part y” or “you have weak area z” or “your spine is unstable,” even if these components may be somewhat true. Reason why comes back to reducing threat perception. Seeing models of bulging discs or using some semblance of the above language tends to just freak people out and moreover is often inaccurate. People just need to know that it is safe to move, when it is safe to move, and move well when they do.
I will finish my education by asking the patient an incredibly important question. Drum roll………………………………
Do you have any questions?
Especially the case with pain neurobiology, if the patient does not understand where you are coming from, they will not be able to fully buy in to your methodology and plan. So make sure any questions the patient has are answered to the best of your ability.
I always finish my interaction with patients with the following phrases
1) “Do you have any questions, comments, concerns, or complaints?”
2) “Is there anything else I can do for you or that I did not cover?”
I ask these questions to again establish an open communication and rapport. I want to make sure that the patient is completely satisfied with the experience that I have provided them. Moreover, finishing the session with the same ending every time they come in provides the patient with some consistency and helps establish your brand; in my case, the Zac Cupples brand.
So there you have it, the above methodology is how I approach a patient interaction. I have based many of these methods on what I have read regarding people interaction, so the below resources might be good to check out. If you can get your social capabilities to a high standard, the rest will take care of itself.
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:
Purpose: Full-body coordinated mobility and stability; linking the hips and the shoulders.
Here is how it is done.
Purpose: Evaluate stepping and stride mechanics.
Here is how it is done.
Purpose: Test deceleration and left/right function utilizing contralateral upper extremity patterns and ipsilateral lower extremity patterns.
Here is how it is done.
Purpose: Evaluate scapulothoracic rhythm, thoracic spine and rib mobility.
Here is how it is done.
Purpose: Tests hip flexion, hip extension, and core function.
Here is how it is done.
Trunk Stability Pushup
Purpose: Tests reflexive core stability.
Here is how it is done.
Purpose: Check multi-planar pelvic, core, and shoulder girdle stability. Also looks at reflexive stability and transverse plane weight shifting.
Here is how it is done.
The FMS is designed to give a corrective pathway that may involve temporarily ceasing potential risk activities. Many things can perpetuate faulty movement, so it is best to control as many variables as possible. Here are some possible activities that may be compromised if one scores lower than a 2 on the screen.
ASLR: Heavy closed-chain loading activities, running, plyometrics.
Shoulder mobility: Heavy or overhead pushing/pulling movements.
Rotary stability: Conventional core training, high threshold training that requires core control.
Trunk stability pushup: Heavy upper/lower extremity loads; vigorous plyos.
In-line lunge: Exercises and loads involving the lunge pattern
Hurdle step: Exercises and loads involving the single leg stance pattern
Deep Squat: Exercises and loads involving the squat pattern.
The Basic FMS
Now I know what you are thinking. “Zac, there is no way that some of my clients can perform all these tasks.” Well, Gray has an answer for you. The FMS does not have to be performed in its entirety, and can be progressed in the following fashion:
BASIC FMS: ASLR, shoulder mobility, and pain-clearing tests.
Rotary stability along with flexion and extension clearing tests