Using the Selective Functional Movement Assessment and Regional Interdependence Theory to Guide Treatment of an Athlete with Back Pain: A Case Report.

Gabby Goshtigian, BS, HFS, DPT Student Department of Physical Therapy, University of New England, Portland, ME

.

Background

Purpose

Case Description

Ankle Hip

Thoracic Spine Neck

Shoulder Wrist

Foot Knee

Lumbar Spine

Scapula Elbow Hand

Results

Left Right Cervical Flexion FN Cervical Extension FN Cervical Rotation DN DN Upper Extremity (LRA) FN FN

Upper Extremity (MRE) DN DN

MSF DN MSE DN MSR DN DN Single Leg Stance FN FN Deep Squat DN

Left Right Cervical Flexion FN Cervical Extension FN Cervical Rotation FN FN Upper Extremity (LRA)

FN FN

Upper Extremity (MRE)

FN DN

MSF FN MSE FN MSR FN FN Single Leg Stance FN FN Deep Squat FN

Initial Exam Discharge

Initial Exam Discharge Joint Mobility • Thoracic Spine: 2/6

• Ribs: 2/6 • Thoracic Spine: 3/6 • Ribs: 3/6

Pain Rating • Best: 2/10 • Worst: 7/10

• Best: 0/10 • Worst: 2/10

Modified Thomas Test (+) (-) Patrick’s Test (FABER) (+) (-) 90/90 SLR Test (+) (-)

SFMA Movement

Patterns

FN = Functional/Non-painful; DN = Dysfunctional/Non-Painful; LRA = Lateral Rotation/Abduction; MRE = Medial Rotation/Extension; MSF = Multi-segmental Flexion; MSE = Multi-segmental Extension; MSR = Multi-segmental Rotation

Figure 16. SFMA movement pattern changes from initial exam to discharge.

Figure 17. Special tests changes from initial exam to discharge.

Figure 18. At discharge, the only SFMA pattern that remained DN was right MRE. The patient was never able to reach the inferior angle of his scapula.

Figure 19. The MRE pattern was functional on the left at the time of discharge.

Skill

Sport Specific

Performance Strength &

Conditioning

Functional Movement Mobility & Stability

The SFMA Patterns Interventions

Reset Reinforce Reload

Discussion

References

Conclusion

Acknowledgements

The SFMA is a useful tool to qualitatively analyze movement and identify dysfunction at, and remote to, the site of pain in order to effectively develop a plan of care and guide treatment in a youth athlete with LBP. It would be beneficial to continue to explore its application, validity and associated outcomes in various musculoskeletal injuries.

The author acknowledges Brian Swanson, PT, DSc, OCS, FAAOMPT for assistance with case report conceptualization as well as Patrick Nelson, PT, MS, CSCS and Brian Bisson, PT,DPT, CSCS, NSCA-CPT for their helpful input, supervision and guidance during patient care. Contact: ggoshtigian@une.edu UNE Dept of Physical Therapy, 716 Stevens Ave Portland, ME 04103

1. Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine. 2006; 31(23): 2724 – 2727.

2. Mallen CD, Peat G, Thomas E, et al. Prognostic Factors for Musculoskeletal Pain in Primary Care: a systematic review. Br J Gen Pract. 2007; 57(541): 655–661.

3. Cook G. Movement. California: On Target Publications; 2010. 4. Boyle M. Advances in Functional Training. California: On Target Publications; 2011. 5. More information about the Functional Movement Systems can be found at http://www.functionalmovement.com/

• The SFMA helped identify subtle impairments remote to the site of pain which may have been missed with a uniplanar.

• RI, identified by the SFMA, surfaced in this patient as impairments at the shoulder, thoracic spine and hip and were determined to be contributors to the patient’s LBP.

• A joint-by-joint pattern emerged and guided intervention as therapists believe that limited ROM at the hip, thoracic spine and shoulder were leading to compensation at the lumbar spine which is designed for stability and doesn’t tolerate excessive movement.

The SFMA consists of 10 fundamental movement patterns help identify meaningful impairments seemingly unrelated to the primary complaint. 3

Figure 1. The joint-by-joint theory by Mike Boyle

Figure 20. Emphasis should be placed on gaining a foundation of proper functional movement before a focus shifts to performance and skill, especially in an athlete.

• Resolution of mobility and stability impairments with a focus on motor control resulted in improved functional movement patterns.

• According to Cook, these basic functional movements are the foundation for higher skills and athletics such as weight lifting and soccer in this patient’s case.

• Without a foundation for proper movement, even young active athletes are susceptible to injury.

• Interventions were progressed using a reset, reinforce, reload structure for a given pattern when it was dysfunctional. • Reset: decrease pain or restore mobility • Reinforce: therapeutic exercise to protect reset • Reload: integrate new gains into functional strengthening pattern

Figure 12. Hamstring stretch (HS) to restore hip mobility

Cervical Flexion

• Soft Tissue Massage • Positioning & Breathing Techniques • Thoracic Spine Manipulation

• Soft Tissue Massage • Sustained Stretching • Joint Mobilizations • High Velocity Thoracic Spine Manipulation

•Static & Dynamic Planks • Bird Dogs • ½ kneeling chops and lifts • Single Leg Deadlifts

Figure 13. Heel elevated toe touch reinforces HS length and promotes posterior hip shift

Figure 14. Deadlift with posterior hip shift strengthens movement in the corrected pattern

• Incidence of low back pain (LBP) is as high as 36% among adolescents and even more prevalent in those who play sports. The majority of these cases lack an underlying diagnosis and are classified as non-specific LBP. 1

• Previous injury and longer durations of pain consistently emerge as prognostic factors in musculoskeletal pain. This affects movement patterns which then continue to contribute to dysfunction. 2

• The Regional Interdependence Theory (RI) views all regions of the body as being musculoskeletally linked, with impairments in remote regions to site of pain often being a cause. 3,4

• The Joint-by-Joint Theory compliments RI by arguing that joints alternate in primary function from stability to mobility and when a joint doesn’t carry out its role, the next joint in the chain will, leading to dysfunction.

• Despite the multidirectional quality of human movement, measurements in PT examination are often uniplanar and lack the functional complexities involved in daily activities.

• The Selective Functional Movement Assessment (SFMA) is a movement-based diagnostic tool which provides a qualitative standard for movement. 3

The purpose of this case study was to explore the use of the SFMA to guide evaluation and treatment in a patient with chronic LBP and provide an example of its application as a framework for clinicians to use in future evaluation and treatment.

•18 year old male collegiate soccer player and weight lifter

• Chief Complaint: Intermittent LBP over last 2 years with a recent flare up over previous 3 months

• Medical Diagnosis: Chronic LBP

• Musculoskeletal Impairments: Limited hip flexion and extension ROM. Grossly limited joint mobility in thoracic spine. Asymmetrical hip strength, R > L. Forward shoulders and excessive lumbar lordosis.

• Functional Impairments: Impaired lumbopelvic control with exercises and SFMA movement patterns.

Cervical Extension Cervical Rotation Lateral Rotation Abduction

Medial Rotation Extension

Multi-segmental Flexion

Multi-segmental Extension

Multi-segmental Rotation

Single Leg Stance Overhead Deep Squat

Figures 2 – 11. All 10 movement patterns in the SFMA. Movements were performed at initial exam and before each treatment session to guide plan of care.

Pain Management Mobility Stability

Figure 15. Interventions focused on symptoms first before progressing to mobility, then stability exercises.