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
This is a chapter 5 summary of the book “Movement” by Gray Cook.
In this chapter, Gray outlines the interconnectedness of the tests and outlines all of the different breakouts. The movements will be demonstrated in later chapters.
There are seven movements with different clearing examinations.
1) Deep squat
2) Hurdle step
3) Inline lunge
4) Shoulder mobility
5) Active straight leg raise (ASLR)
6) Trunk stability pushup
7) Rotary stability.
The first three movements are often called the big 3, as they are functional movements that check core stability in three essential foot positions. The remaining four are considered fundamental movement patterns. Often these patterns are attacked before the first three.
These screens can also be broken up into those that check symmetry and asymmetry:
Trunk stability pushup.
The way we work the FMS is by first attacking asymmetrical patterns before straight patterns, and primitive patterns before functional patterns.
The FMS is scored on a four point ordinal scale with the following scoring criteria:
3 – Complete pattern
2 – Complete pattern with compensations/deviations
1 – Incomplete pattern
0 – Painful pattern.
There are also three clearing tests that are either positive or negative for pain.
1) Impingement clearing test (shoulder mobility)
2) Prone pressup (trunk mobility)
3) Posterior rocking (rotary stability)
The FMS works by creating several filters to catch for compensations and problems.
1) Pain – Signal to a problem.
2) Decreased movements – Even though these movements go less than full ROM, compensations can be caught with multi-joint movements.
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.
This is a chapter 2 summary of the book “Movement” by Gray Cook.
There are anatomically two basic types of muscles; shunt and spurt. Shunt muscles compress and produce structural integrity because the distal attachment is far from the moving joint. Spurt muscles produce movement because the distal attachment is close to the axis of rotation. While these two muscle types are present, they can vary depending on the function performed. For example, if we perform a movement in the closed chain, the spurt and shunt roles become reversed.
Focusing on a single muscle group causes us to lack understanding of the supporting matrix behind superficial muscle action. Muscle function depends on body position and joint in action.
We can see this point illustrated in Lombard’s paradox, which involves the coactivation of hamstrings and quadriceps when performing a sit to stand. These muscles are antagonistic to one another at their respective joints, yet movement is produced. The resultant effect is the quads and hamstrings becoming global stabilizers.
Muscle activity is task specific, therefore Gray purports four types of muscles:
1) Global Stabilizers: Multi-joint muscles contracting to produce stability and static proprioceptive feedback.
2) Global Movers: Multi-joint muscles that produce movement and dynamic proprioceptive feedback.
3) Local Stabilizers: Deep segmental muscles (1-3 segments) that produce stability and static proprioceptive feedback.
4) Local Movers: Single joint muscle that produce movement and dynamic proprioception.
These different muscle types require different training modalities. The example given is stabilizer muscles. These muscles cannot be trained with concentric/eccentric modalities for this will not change the real issue – timing and recruitment. Authentic stability is about effortless timing and the ability to go from soft to hard without a blink.
Joints, Ligaments, Fascia, and Breathing
Here Gray discusses how decreased muscle function affects the joints.
Muscles decrease function → joints are stressed→ microtrauma/wear→ Stiff joints give poor feedback→ Muscular demand increases→ Muscle imbalance, inhibition, and guarding occurs.
Both joints and ligaments interact with the nervous system to give us joint position sense, direction, and movement speed. This feedback affects how muscles react.
Fascia also plays a crucial role by redirecting stress and providing dynamic structure. The fascia is what links all the muscles together and facilitates muscle synergy to the nervous system.
Breathing is what connects the entire movement matrix, yet it is often the most neglected area for testing. A good breath can relax the system in the presence of stress and dysfunction. Breathing also has the ability to stimulate the parasympathetic nervous system and increase heart rate variability (HRV). Breathing dysfunction very much parallels movement dysfunction. If one cannot maintain a quality breath at end-range, then the movement is not authentic.
The Neuromuscular Network
One goal of the sensorimotor system is uprightness. This quality depends on three components:
1) Vestibular – head position
2) Proprioceptive – Body segments
3) Visual – Body relative to environment
These three areas account for constantly changing posture, as we must adjust to an ever-changing environment. The hands and feet in particular also play a huge role in how we interact with our environment.
When we talk about movement and injury, it is important to understand that pain experiences can alter motor control at multiple joints away from the injured sight. This is a highly individual and unpredictable process, and the lack of pain does not equate with normal movement or no risk factors.
While there are many different discussed points in the above section, the reason for this is that everything is very much interconnected. Highlighting one system neglects the others and does not paint an accurate picture.
There are three types of movement dysfunction:
1) Developmental – movement opportunities become denied.
2) Traumatic – Compensations stress other body regions. Baggage follows injuries.
Oftentimes developmental and traumatic dysfunction are very difficult to change. On the other hand, acquired dysfunction can readily be changed. There are two types of acquired dysfunction.
1) Unnatural activity repeated on natural movement base (throwers, unilateral sports, habitual postures).
2) Natural activity repeated on an unnatural movement base (fundamental limitations and asymmetries).
Changing acquired dysfunction does not necessarily mean moving more. Moving more does not equal moving well. We need to target particular dysfunction.
This is a chapter 1 summary of the book “Movement” by Gray Cook.
This chapter’s central point, and for that matter the whole book, is that movement needs to standardized just like all other therapeutic and performance measures. Movement is fundamental to who we are.
Despite movement being at our center, we continually classify patients and clients by body region. Unfortunately through this reductionism, much is lost. We cannot measure parts and expect that to give us an adequate picture of the whole.
Before we begin training, it is advocated that movement be screened to facilitate an optimal training environment. The screen will determine movement as one of the following three areas:
Movement is screened for many reasons. Gray often states that the number one risk factor for injury is previous injury. A movement screen helps find potential risk factors for re-injury. Moreover, if movement is dysfunctional, then all things built on that dysfunction could predispose one to more risk.
The screen also helps separate pain from movement dysfunction. It is widely known that when one undergoes a pain experience, motor control is altered. Because motor control is altered, we may not get the desired training effect secondary to pain. Pain screening gives us an avenue for further assessment a la the Selective Functional Movement Assessment (SFMA).
Movement screening is the first step away from quantitative analysis to movement quality; from reductionism to holism. Once we have a basic movement map we can take a look at quantity. This framework also helps us better understand the person in front of us, as humans tend to operate in patterns and sequences.
Reductionism creates a paradox between movement and motion. If we assume that a joint has full motion, then by reductionism movements involving the joint will be normal. This thought is often not the case. That is because movement requires motor control, which is the combination of stability, balance, postural control, coordination and perception.
Function vs. Anatomy
It is important to understand the function and anatomy do not always correlate. Take weakness for example. Weakness can occur for a variety of reasons:
The above three examples cannot change weakness based on strengthening alone. If you take tone for example, it is often present to protect the person from accomplishing a task. Muscles do not tighten just because.
Mobility before Stability
When treating movement dysfunction, it is important to first decrease mobility restrictions as able. Once we have established normal mobility, we can cement that new range with stability training. When mobility returns, there is a short window for motor control to be re-established. However, the appropriate stability training dosage must be given. If we go too hard, stiffness will return; but if we do not go hard enough, the pattern will not change. We are essentially hitting the reset button, then reprogramming new software.
Five Principles of Functional Movement Systems Logistics
Here are the 5 movement tenets per Gray.
1) Basic bodyweight movements should not provoke pain.
2) We should not have gross fundamental movement limitations, even if pain-free. For this deficit will lead to substitution and compensation, which will decrease efficiency, which will lead to secondary problems, which will increase injury risk.
3) Establish movement fundamentals before performance.
It has been a great and even nostalgic experience thus far. I remember just a couple years ago being in this young lady’s shoes having the same successes, failures, and questions she has now.
I think working with me may have been quite a difference from the scholastic framework that she was accustomed to. This difference is because our common theme for the week was wait for it…………………………………….The Brain.
Most schools, especially in the orthopedic realm, teach about developing physical therapy diagnoses and treating various pathologies. However, we had a couple different cases in which we didn’t necessarily nail down a pathology yet got fantastic results.
The first patient we saw was a lovely middle aged woman who was classic for the biopsychoscial treatment model I espouse. She comes into seeing us with chronic low back pain over the past 3 years, has had several TIAs, been diagnosed with an eating disorder, and generally lives a stressful life. Our comparable sign for the day was flexion which was at 50% range and painful (or DP for you functional movement folks out there).
We discuss what we think is going on and the first words out of my intern’s mouth: Central Sensitization. Music to my ears, I think she will do just fine.
Our next patient was a middle aged man coming to us for medial knee pain that began while playing volleyball. Upon observation, big findings were general hypermobility with a slight limitation in knee extension on the involved side. Our comparable sign for the day was stair negotiation.
This gentleman came in with the same frame of mind as the lady above, what is wrong with me, what structure is making me painful. His complaints were very vague and difficult to reproduce except for stairs. We perform a similar treatment to above–Explain pain, breathing exercises combined with some hip activation–and guess what happens? Knee extension mobility returns to full and decreased symptoms with stairs.
Once we finished with this patient, my intern asked me what I think was wrong. My answer: It could be a thalamus problem.
In both of these cases above, I could not pinpoint an exact “structure at fault” as we both were often taught in school, yet both patients improved. I am inclined to believe that more and more that the structure at fault is and always will be the brain.
If you look at most of the research regarding anatomical correlates and pain, it is not so good. Depending on who you look at, 30-80% of asymptomatic individuals have abnormal MRI findings. Pain and structure do not always go hand in hand, and moreover, we are not very good at determining a structure. The most recent editorial in JOSPT by Paula Ludewig and a friend of mine Becky Lawrence discusses this problem, and it is definitely a step in the right direction.
Since we are not so good at finding and probably treating pathologies, I propose instead that we start treating people; people who are undergoing a pain experience that is compounded by multiple factors. That neck pain that fits a closing pattern may not have hurt if they did not undergo a stressful event a week prior. Even though we are always operating under some degree of uncertainty, the way we approach treatment ought to follow a similar step-by-step process:
Rule out any potential red flags. Make sure they are someone you can help.
The most important thing you can understand is that no one has the answer for all pains. Pain is entirely individualistic, hence requiring different answers. There are several strategies which one can undertake to triumph over pain.
Tool 1: Education
Knowing how pain works is one of the most important components to overcoming pain. Instead of no pain, no gain, the authors like to use “know pain, or no gain.” Understanding pain is essential for squashing fear of pain, which leads best toward the road to recovery.
Here are some important concepts to be known about explaining pain.
Anyone can understand pain physiology.
Learning about pain physiology reduces pain’s threat value.
Combining pain education with movement approaches will increase physical capacity, reduce pain, and improve quality of life.
Tool 2: Hurt ≠ Harm
It is important to understand that when someone feels pain it does not equate with damage. The same can be said with recurring pains. These pain types are often ways to prevent you from making the same mistake twice. If your brain sees similar cues that were present with a previous injury, the brain may make you experience pain as a way to check on you and make sure you are okay.
Just because hurt does not mean harm does not mean you can get crazy though. Because the nervous system is trying to protect you, it will take drastic measure to prevent re-injury. Therefore, the best option is to gradually increase activity levels without pressing past the nervous system’s threshold.
Tool 3: Pacing & Graded Exposure
All the body tissues are designed for movement, therefore this is how we will increase activity. Here are the steps to pacing and graded exposure.
Select an activity you want to do more of.
Find your baseline – The amount of activity you can do that you know will not cause a flare-up. A flare-up is an increase in pain that leaves you debilitated for hours to days.
Plan your progressions.
Don’t flare up, but don’t freak out if you do.
It is a lifestyle change, requiring a little bit more planning.
Take walking for example. Suppose you know you could walk for 5 minutes, but if you did 7 you would pay for it over the next couple days. You might walk for 5 the first day, then 5:15. Eventually, you would work up to past 7 minutes, then so on and so forth.
Access the Virtual Body
Just like the body, the virtual body can be exercised as well. Ways to work on the virtual body are as follows:
Mistake Recovery – Training to recover from worst case scenarios.
Here were Lee’s recommendations for program design.
Skill acquisition – The ability to control desired movements. This portion can be trained by either skill components (3-4 exercises), skill itself (1-3 exercises), or linking skills (shuffle to sprint).
Force application – Performing the desired movement patterns with increased force or resistance.
Random reactive training – Challenge movements under a random setting, but make sure the above 2 components are rock solid first.
Here were Lee’s recommendations to progress to reactive training
Acceleration → deceleration → Change of direction →One direction reaction → Multi-direction reaction.
Some great cues that Lee used
Stay in the tunnel.
Arms long and strong.
Tear the paper – Get in the athletic position, load the big toes, and try to rip the floor apart.
Stop in front of a person.
Here were my favorite Lee quotes.
“The biggest component of developing multi-directional speed is being able to re-accelerate.”
“Do the most important things often.”
“We don’t teach pivoting. Open hips and retreat.”
Reactive Agility – Nick Winkelman
The first thing Nick did in his presentation is define agility, which he says is the ability to change direction and react; the ability to quickly make a decision. Both of these qualities therefore must be tested.
To test change of direction, many of your traditional tests such as 5-10-5, T test, L acceleration, can be utilized. The important thing to understand is that you only need to utilize one of these tests because they are all looking at the same thing. You want to pick one that best captures the movement you are looking for.
Before testing reactive agility, we must first discuss reaction time’s two phases. First is the latency phase, which is the time between receiving stimulus and the appearance of EMG in relevant muscles. The second key and trainable phase is response phase, which is the time from EMG appearance to motor action. The response phase is predominantly what we test, and the ability of one to respond to relevant cues is what separates the good from the great.
The big test that Nick used was the reactive agility test (RAT), which I will demonstrate in this video below.
What is nice about the RAT unlike your traditional agility tests is that we can look at asymmetries in both movement, decision-making, and accuracy. Moreover, he presented a lot of good research in support of the test.
With the RAT, you can also group athletes into how fast one moves and reacts based on ability to change direction and react. This bucketing allows you to train athletes based on necessary qualities. Here are the categories:
Fast Change of direction
Slow change of direction
Fast mover/thinker (elite)
Fast thinker/slow mover
Fast mover/slow thinker
Nick showed us several different drills utilizing the Fusion Sports Smartspeed light system to train these qualities. For most, this system is likely not in the cards to utilize. But as long as you apply the above principles, you can add a reactive component to most any activity.
Here were some other interesting tidbits from this presentation.
Human delay before you become aware of things is 300-500 ms.
Reaction time is subconscious
We react fastest to auditory cues, next to tactile, slowest to visual.
Post-injury strength returns in 6 months, whereas rate of force development takes up to 1 year.
The Science of Coaching: Applying Theory in Practice – Nick Winkelman
First, Nick talked about the classic Fitts and Posner three stages of motor learning, which are as follows:
Coginitive → associative → autonomy
Each stage requires different coaching styles. Generally, earlier stages require more feedback than later stages. You also want to transition toward having the athlete/patient describe what was done right in an activity.
It is also important to maximize context, as this helps facilitate better memory. The athlete retains and progresses more when they know rational why, how the activity felt, and what needs to be done next. Telling stories and using sticky phrases is also very helpful.
Nick also discussed attention regarding how it is the filter for all information. Understand that we all have similar attention span, it is just that some activities require more attention than others. This is most evident comparing a novice and expert performing the same activity. The activity is old hat for the expert, thus requiring less focus to perform. The novice, on the other hand, is just learning the activity and must pay greater attention when performing.
Transitioning these principles to coaching, Nick designed a framework for coaching that involved practice design at the foundation, followed by instruction and feedback.
First, let’s discuss practice design. The goal of practice design is to optimize learning and retention. The way this goal occurs is by both varying movements and context as well as interfering with the context. You want to have your athletes struggle and have bad days in practice. If this part does not occur, then we go into autopilot and learning is not facilitated.
Contextual interference also occurs by performing practice in either a blocked, serial, or random fashion. Many people tend to think that random is the way to go for motor learning, but it really depends on multiple factors:
Generally, the younger the age, the lower one’s skill, and the more complex the activity, the more block practice should be utilize. As these qualities hit the other end of the spectrum, random practice becomes more desirable.
The biggest takeaway from this portion was that most people over-coach. Generally 1-2 positive focus cues are needed at the most to build awareness. You also want to start and finish instructions with what you want versus don’t want.
When it comes to cueing, externals are key. By external cues, I mean that attention should be focused on the desired outcome as opposed to the internal process. Let’s take a pushup for example. An internal cue might be “pull your shoulder blades together, and then straighten your arms.” Whereas an external cue might be “rip the ground apart, then push the ground away from you.” When utilizing external cues, less attention span for the cue itself is required, therefore allowing for automatic motor processes to occur.
It is also beneficial to watch others perform activities. This change occurs due to mirror neurons which are present in the brain’s motor cortices. Benefits can be achieved by watching both experts and novices; experts by seeing the activity done correctly, novices for improving problem solving.
Nick listed two types of feedback.
Knowledge of results – Information about the outcome (quantitative) [E.g. You ran 4.5 in the 40.]
Knowledge of performance – Information about movement characteristics that led to the outcome (qualitative). [E.g. drive your knees more during the first 5 yds.]
In terms of feedback quantity, it can be detrimental to give too much feedback unless that feedback is external. The problems with too much feedback include coach dependence, less self-independnece, people becoming practice champions because there is no retainment, and paralysis by analysis. If we relate quantity to motor learning stages, less feedback should be given the further along they are. Research demonstrates that cognitive stages should get feedback 100% of the time, and associative stages 33% of the time. Research also states that athletes want feedback only 8-10% of the time and only if it was the right movement/activity.
My favorite lines from this presentation:
Art is when we don’t understand how something is.
Movement efficiency is the opposite of learning. It is okay to make errors.
Shoot for 60-70% success and 30-40% failure.
Visual memories last better.
“Movement needs a goal” [On external cues]
Don’t tell athletes things they already know.
Use noises to reinforce movements (BOOM, SNAP).
Overall, the course was excellent and one of my favorites for the year. Learn as much from these guys as possible.
There are several people who would like to help someone in pain, with each person offering a different explanation and solution for someone’s pain. Research has shown these conflicting explanations can often make things worse. The one who has the most power over pain is the person who is in pain.
Here are some general guidelines for someone dealing with pain.
Make sure any injury or disease which requires immediate medical attention is dealt with. All ongoing pain states require a medical examination.
Make sure any prescribed help makes sense and adds to your understanding of the problem.
Get all your questions answered.
Avoid total dependence on any practitioner.
Make sure your goals are understood by you and the clinician.
The clinician’s ultimate job is to assist you in mastering your situation.
Models of Engagement
There are 5 interchangeable models which enable both the patient and the clinician to identify the processes underlying pain.
The orchestra model – Pain is a multi-component process that manifests itself in the brain and goes through many pathways. There are many players involved in the pain experience, hence the orchestra, with the brain as the maestro.
Fear-based models – Fear of pain and reinjury are major forces behind the development and maintenance of chronic pain.
An evolutionary model – Pain protects the tissues in order to ensure species survival.
A clinician decision-making model – Pain is very personal, and therefore a plan of care should be developed exclusively for that person.
When working with a healthcare provider, they should be able to answer the following questions:
What is happening in my body?
How long will it take to get better?
What are all the options for management?
What can I do for it?
What can you do for it?
Is there anything that requires special attention?
What do my physical findings really mean?
Coping aims to reduce the threat value of the stimulus and the associated emotions and altered biology. There are various ways coping can be done, with some better than others. Generally, active copers manage pain and other health issues better than passive copers.
There are several patterns in which we react to pain.
Hurts don’t do it – Pain kicks in at a certain amount of activity, then we stop once it starts. Over time we can perform less and less activity before pain occurs, leading to disability, disuse, and likely depression.
Boom-bust – Pain comes on but you push through it and ignore it until suddenly the pain becomes unbearable. Here, your nervous system busts. A cascade of danger chemicals floods the nervous system leaving you completely wiped out for days to weeks.
The commonality between these two patterns is that both lead to eventual activity limitation. We want to be somewhere in the middle.