Recorded in Quebec, October 2012, at the International Federation of Orthopaedic Manipulative Physical Therapists Conference, where Gray was a keynote speaker. This talk was recorded and provided to us by the Canadian Physical Therapists Association, which you’ll find at physiotherapy.ca. We thank them for allowing us to republish this talk.
I’m going to take some time today to try to condense, in 40 minutes, about 20 years of work and scrutiny in my own practice.
I’m not going to try to tell you what to think. I’m going to ask you for a moment to think outside the box, because the only way you can truly appreciate your profession and some of the things you do in your profession is to look from the outside.
I almost think that’s what philosophy is. If we look from the outside at some of the things we practice and do, are they based on our habits? Are they based on a narrow scope a mentor may have provided us? Or are they based on some evidence or fundamental principles?
We have to use both. The evidence will fluctuate because we’re going to learn different ways to look at things, but there are fundamental principles in growth and development.
In physical therapy when we’re dealing with people from birth to three years of age, we don’t obsess with a goniometer and a manual muscle test. We look at developmental milestones. As long as a child meets that window—as long as children are crawling, rolling and standing by a certain age— because they made the milestone, we don’t obsess on the minute details and impairments. They did it in their own ways, yet they still fit some degree of normalcy.
If those milestones help us successfully manage, treat and diagnose from birth to three, what happens to those milestones when we’re managing people beyond age three?
Is it ever okay to lose the ability to deep squat? I know there are people who have hardware or a fused ankle who cannot deep squat, but in a normal population—think about this for a second because what I need you to do for the next 10 minutes is to stop thinking like a clinician. Ask yourself questions like an epidemiologist.
In almost every other profession in medicine, we look for signs before we get the symptoms. Think about it. Think about the way we manage cardiovascular issues, blood testing, how we look at triglycerides and other markers. Think about how we manage visual systems. Think about how we look at the pancreas.
In modern medicine, we’re looking for signs before the symptoms present themselves, but what do we do in orthopedics? The symptoms walk into our office. We work backward, identifying all the signs we assume or know are contributing to that.
Are there biomarkers for movement that demonstrate injury risk?
We know some injuries are unpreventable. I work with the NFL. I get the unbelievable opportunity to work with special operators in the States. They’re going to get injuries. The more active people in our population are going to get injuries. But injuries are going up—not down. We have consistently lowered standards for the United States military since 1965 just to get enough people to serve.
Don’t think like a clinician. First of all, let’s think about those signs and symptoms. Let’s really think for a minute. Imagine this as a physical therapist: What if you had a chance to give people yearly musculoskeletal checkups? I think it would give us a chance to intervene and attack some of those problems.
How many metabolic problems do we have that are probably causing obesity, things that go back to orthopedic issues that keep people from moving as much as they’d like to move? We see that all the time. When we’re working with people on weight loss, as do a lot of the trainers we train to do movement screens, we find most people who have an obesity issue also have an underlying mismanaged orthopedic problem.
The minute they start exercising, what happens? They stir up the orthopedic problem. Next they get jacked to the medical model. Now they’re on NSAIDS. Their cortisol levels go up and guess what happens? Do you think they lose weight or put on weight? Every time they try to exercise, they have a bad experience. They have poorly managed orthopedic issues.
We need clear biomarkers for risk of injury. We need to know, first of all, what is acceptable. Believe me, I am not policing movement perfection. We don’t all need to rush out and join a Pilates studio, a CrossFit box or go grab kettlebells. That’s not what I’m saying.
I’m saying we have to look at movement patterns like we look at blood pressure.
Screening does not mean assessment. Our work has been misconstrued many times because people see our movement screen, bring it into the clinic and say, ‘No, no, no. That’s too high a threshold test for somebody in low back pain.’ But we’ve already said pain is contraindicated for a movement screen.
A screen is like taking blood pressure. When I take your blood pressure, it doesn’t tell me why you’re hypertensive. It just tells me if you’re hypertensive.
The first goal of a movement screen should not be to diagnose anything, because we shouldn’t be screening a person who already has an issue. We should be assessing and evaluating.
But if we had an opportunity to do a checkup—a musculoskeletal checkup—what would many of us do right now?
We would hit them with a barrage of impairment measures, and we’d always find something. These are called false positives. We could do MRIs on every spine in here today and be amazed that some of you even got here this morning, but you’re doing just fine. We shouldn’t even be looking at that because it doesn’t seem to have a direct correlation with function.
If we’re going to screen, and screen appropriately, we need to first screen people who don’t have symptoms and who don’t have issues. We need to find out what’s acceptable and what’s not acceptable. If we apply a simple test to the normal population, like forward bending, single-leg stance, squatting or reciprocal reaching, we will see a huge bell curve. Some of those people, when they score poorly on those movements, will be at risk. Some people will not do great, but will be above the cut.
Remember, there’s only one number difference between hypertension and non-hypertension. Who had the right to put that line there? Who had the gall to put that line there?
Millions of pieces of data put that line there. It doesn’t mean you’re right up against hypertension with one click over, and one bad day you’re in that category. My point is somebody drew a line. That line is operational and it helps us categorize.
We could probably change the physical landscape of our communities and our countries if we had a yearly musculoskeletal physical. Dentists have it. Do you think they actually look in your mouth to see if you’re brushing your teeth or flossing? They don’t. They know if they get a chance to look in your mouth twice a year, take a history twice a year and look at a few biomarkers once or twice a year, they can actually save money for insurance companies.
That’s why insurance companies in many cases pay to have our teeth cleaned. It’s not because they don’t believe we’re brushing. It’s so a skilled clinician can look for things that could potentially cause problems.
This is based on the data.
What do we know about injury risk? We know previous injury is the number one risk factor. We can look at this and say it should always be part of our history, but I think we should also remember that a large part of that statistical population has already been through rehabilitation.
This is what we in Virginia call a little bit of a come to Jesus moment. If people who have been through rehabilitation have been discharged asymptomatic and yet still have a high risk factor, something in the rehabilitation process was left undone.
I have to own that. You have to own that.
If we know they’re going to have a long-lasting disability after rehabilitation, it’s part of our discharge instruction. However if we tell them to get back to their Iron Man competitions or get back to work or play, they’re assuming all is normal.
This is a big issue. Asymptomatic patients are not necessarily functional. It’s important to get them asymptomatic as soon as possible. Many of them will just self-discharge and leave us.
But the point is, the minute they’re asymptomatic we do a different test than the assessment done when they were symptomatic. We do this to demonstrate the risk and to make a responsible prognosis in the next movement they’re going to do.
They’re going to come to us for exercise recommendations. ‘Should I go to a personal trainer? Should I join a gym? Should I do this?’ We don’t just make that judgment on past history. Your personal fitness enthusiasm or fitness endeavors have nothing to do with your professional operation. I don’t care whether you’re a gym geek or not. It doesn’t matter.
You can make intelligent recommendations—how much exercise, the volume, the intensity, the frequency, which patterns they should be doing and which they shouldn’t be doing—based on a screening process instead of your preference for exercise.
That’s what happens a lot. Our enthusiasm and preference for exercise sometimes seeps into our recommendations at discharge, but just remember this: We discharge people who are asymptomatic, but who are not necessarily risk-free.
That’s why that statistic is there.
Now, these are listed in order of priority. The next two are asymmetry and motor control—not flexibility and not strength. These are things we measure, but they’re impairments. If these impairments cause asymmetry in motor control, they’re risk factors.
However, if you measure a weakness and it doesn’t change a movement pattern and they’re fully functional in the movement pattern, it is an isolated impairment. I would recommend watching it, but we have no evidence to say there’s a lot of risk associated with it.
It’s the same thing with flexibility. A lot of the research on flexibility is inconclusive because these measure things passively and don’t look at what happens when you’re on your feet. It has to be a functional pattern because that’s behavioral.
The last one is stupidity. I don’t have a lot of references for this, but just go on YouTube. Email me if you don’t find anything. As far as stupidity is concerned, you can often prove it, but I don’t know if it can be fixed. This is my statement on that.
Back to the risk factors, I think the previous injury statistic is a loaded statistic. Of the people who have had a previous injury, have been through rehabilitation and at some point were asymptomatic at discharge, they probably still had movement pattern asymmetries or motor control issues.
We need to assess our patients on intake and deal with whatever diagnosis and functional diagnosis is presented. But unless we screen them on discharge in a systematic way—a standard operating procedure—we’re not going to be able to give them the valuable information on prognosis.
We may say, ‘I need you back here once a month just for a recheck,’ or, ‘I need you to join a gym, but not just any gym. The gym you’re going to join and the person who’s going to be training you understands the system I just put in place.’
I trust a lot of our strength coaches, athletic trainers and personal trainers to execute corrective strategy as long as there are no symptoms involved. They can follow that. They need programming.
That’s why we invented the Functional Movement Screen. It is a utility test for non-medical professionals so they will refer appropriately. However, we have to have a different perspective on movement because it will help foster prediction, prognosis and exercise progressions.
That’s something I’m absolutely passionate about.
Today we have a roomful of some of the best manual therapists in the world. Manual therapy offers us an ability to reset the neuromuscular system. We know that because we measure things, do things and then things change with no active participation from the patient. Boom! We stick a needle or we do something, and something changes. That’s a reset.
But assuming that reset is going to hold as the patient exits the table, enters the parking lot, goes back to the gym or bends over to pick up something is an assumption we can’t make.
Starting with competent manual therapy is always the best reset, in my opinion, when symptoms in a musculoskeletal situation are present. The system is running out of control and is not policing itself. It has adopted a compensatory behavior and that behavior has become normal in a behavioral model in the neuromuscular system.
You have three checklists you have to do if you work in our clinic.
Demonstrate a reset
This means you changed something without active participation from the patient, or you guided the person through something.
This can be taping, bracing, education or maybe the instruction to ‘Stop sleeping on your stomach’—all of the wonderful things we say to de-complicate the problem.
There are two categories of reinforcement—protective or corrective. Many times when I see a foot that’s beyond help, an orthotic is a protective measure, not a corrective measure.
When I lay a piece of tape across a knee, I hope you won’t need that tape a month from now. It allows you to do something you wouldn’t otherwise be able to do. It imparts some degree of sensory input. It helps perception, and that’s a corrective measure.
We use them both.
This is when we pick a pattern that supports re-entering the good movement pattern and riding over the old one. We’ll see a patient with low back pain, perhaps pain on forward bending, who is very dysfunctional on right single-leg stance.
A lot of people go right to single-leg stance training. Single-leg stance in the neurodevelopmental sequence starts with rolling because you roll around an axis. Establishing that axis creates the next pattern—crawling, then creeping, then half-kneeling, then tall-kneeling, then squatting and then standing.
Then comes single-leg stance. You can see the first time single-leg stance was loaded on the system, it was done so with adequate, appropriate and well-timed sequential rolling.
Yet when we train single-leg stance, we think we’re working on a glute medius problem and we’re not. That’s one thing I had to learn the hard way as a young manual therapist. I would do the manual therapy my mentors asked me to do, and then simply exercise the local kinesiology, thinking the problem was just going to work itself out.
When you have a computer virus, does it just work itself out or do you wind up at the Mac store watching a genius do stuff? It doesn’t work itself out. You can hit ‘reset’ as many times as you want, but the virus will not work itself out.
Many of our movement pattern behaviors are almost pathological. Yet it’s so normal that we can’t break the habit. We can’t stop doing it.
The argument for asymmetries comes in athletics. Most of our athletics are asymmetrical. What we see is the further away—the more distal—the more asymmetry we expect in performance measures and skill, but the more central it gets. When we see asymmetries in motor control, especially in the core, as in half-kneeling, quadruped diagonals and things like that, these are detrimental even if you’re a pitcher, a kicker or a golfer. If we get out toward your fingertips, we can expect an asymmetry. The closer we get to the core, those who maintain their symmetry the best actually seem to do better according to our statistics.
Here are two mistakes I hope you can learn from.
First, as a young therapist I thought my diagnostic tests would accurately and consistently discover dysfunction and predict risk for injury. I incorrectly assumed individuals with the same impairments would have the same movement pattern behaviors.
Now imagine that. How many times in the clinic have you seen the same person, the same post-surgical diagnosis or the same symptomatic issue, and yet the individual movement motor control system adopts a different pattern?
Let’s think about the exact same low back pain symptoms between sleep, awake and activity. This person has pain with forward bending. That person has pain with rotation. This person has pain with backward bending. They have different movement behaviors. We look for structures causing this, when a simple tweak in motor control can make the same low back pain symptoms in all three of those patterns.
Medical diagnoses and impairment measures are absolutely vital to problem-solving, but if we don’t profile movement behavior, we won’t separate the painful patterns from the dysfunctional patterns we now know can be risk factors.
Secondly, when it’s time for a competent manual therapist to suggest exercise, a small isolated exercise or a big gross pattern, we cannot base that exercise suggestion on the local kinesiology around the injury.
Regional interdependence has taught us we shouldn’t do that. What we should do is separate the dysfunctional patterns that are asymptomatic from the functional or dysfunctional patterns that are symptomatic.
Where is our exercise intervention going to be? It’s on those that aren’t symptomatic. You can have pain with forward bending, but if your single-leg stance on the right is just sloppy, I can attack that with restorative exercise while I’m treating the flexion or extension problem in the sagittal plane.
For the most part, there’s really not a situation to exacerbate things because I picked a non-asymptomatic pattern to exercise to re-establish motor control. It’s a biomarker of dysfunction. It is going to contribute to the risk factor. It is something I should take off the table.
When in the acute injury, I can do this without exacerbating symptoms. Our first exercise intervention should be at a non-symptomatic dysfunctional pattern. That was an ‘aha’ moment for me in the clinic. Think about all of the things that aren’t normal that we should be addressing to create a better discharge platform.
If you got a chance to do pre-participation physicals in athletics, in a work setting or in the military and are invited to back to see what the medical people are doing, this is a freshman mistake in orthopedics. Doing your special tests and impairment measures or doing some type of isolated strength tests and trying to predict function would be incorrect. You’re bringing diagnostic tests to somebody who has not even self-placed in a category to be diagnosed. They are normals. They are asymptomatic and pain-free.
That’s what we think, but here’s a sobering statistic. The Functional Movement Screen is comprised of seven simple one-repetition whole-body movement patterns. When we apply those patterns to children, workers, military operators and athletes who have passed a pre-participation physical and given clearance to do whatever it is they’re getting ready to do, we have a 20% fail rate due to pain with movement in people who have passed a medical physical.
This is simply because we make them go through full deep squatting. We don’t stop their squat at 90 degrees. We want to know if they can squat, and if they do, does it cause symptoms. We’re actually finding injuries in asymptomatic populations, in populations who have not declared themselves as patients.
If you disagree with every other rating and ranking scale in the Functional Movement Screen, then know this: A simple battery of seven movements over 10 minutes demonstrates pain in over 20% of the people getting ready to go into an athletic or strenuous endeavor who have been declared healthy by a physician. It’s simply because we haven’t ’fessed up and said, ‘We don’t have biomarkers for movement, but we’re going to diligently look for those.’
I’m also a strength coach. You don’t have to wear a Viking outfit to be one, but some days it just works out better for you. Somebody at a conference saw that picture, and said, ‘That’s cool. You dress up with your kids for Halloween.’ No, it’s just Tuesday night. The wife likes the Viking outfit.
There you go. I have no excuse.
As a naïve strength coach, I thought performance tests would help predict injury. You’re going to see a lot of people doing that. They have tests where kids drop down off a box and they see that valgus collapse. Come on. Everyone in this room can step up a little bit better than that.
Watching people jump off a box and arbitrarily, subjectively calling this a valgus collapse—we know it could be a mobility or stability problem. They could have poor control of the pelvis. They could have a locked-up ankle forcing them to pronate and collapse. They could be seeking some degree of support and they’ll use their MCL if they don’t have a good, reactive quad.
Many things can cause a valgus collapse, but when kids jump off a box and then basically have a valgus collapse, how many different individual exercise regimes do they get? Or do they get a ‘one-size-fits-all let’s teach you how to jump’ program?
Does coaching them how to jump actually go back and get the single-leg stance problem—dorsiflexion restriction, inactive glute on one side or poor abdominal control on the other side? It doesn’t get that. Simply demonstrating they can’t jump is a biomarker for risk of injury, but it doesn’t give us an ordinal scale of how they should be treated differently.
One of these children could have a locked-up ankle and simply need some good manual therapy. The other has a huge motor control issue and probably shouldn’t be jumping for four months. We don’t know which because the attitude is ‘one size fits all.’ You can’t jump? Let’s teach you how to jump.
Jumping is not the problem. It’s a skill laid on top of a bunch of faulty biomechanics and motor control issues. We cannot do a performance test and assume things.
This is a study and we’ll see quite a few of these. Obviously, we know that a valgus collapse over time is going to create some problems, but we could find 10 or 15 different causes. We can’t do performance tests because those test physical capacity.
We know one of the reasons some people are better athletes than others is not because they’re so physically gifted. They have a neurological system that can overcome wet turf, an arid day and dehydration. They have an ability to resist fatigue better than the rest. They compensate better.
That’s literally what athletes do, so we have to come in under what they do well and see if they have cracks in the armor. We have to do the same thing with firefighters. We have to do the exact same thing with industrial workers who are expending almost the same amount of calories as athletes. Just because they can do what they do at a high skill, high physical capacity level does not mean they’re free from micro-trauma and movement pattern erosion.
The first ‘aha’ moment I had was the realization I can’t bring my clinical tests to a normal population and get a consistent biomarker or prediction of who is going to get injured. Likewise, I can’t bring over the performance tests. Performance tests tell us who performs better. They don’t tell us about something that I want you to start thinking about in your practice—durability.
When people leave your practice, they should have a stamp of durability. It’s not because your therapy is so good, or because your skills are so good. It’s because your discharge criteria established whether they’re still at risk, whether they’re asymptomatic or not. That’s how you put a durability rating on people.
We’ve been forced to do that in a pressure cooker. We would show up at the NFL Combine and suggest, ‘Regardless of this guy’s past medical history, he’s been rehabilitated successfully and has a great prognosis. Or…this guy is asymptomatic, but he’s a train wreck.’
We put ourselves in situations of really trying to predict with varying levels of stress who is going to break down.
Durability tests for movement and performance tests for movement are different. They’re different animals. Running and jumping on a force platform is about a four-bodyweight maneuver. Lots of things can cause that valgus collapse, but do we even need to go to four times bodyweight when someone squats like this?
Think of all the different scenarios. People could squat perfectly and have a poor landing. They could squat poorly and have a poor landing. Or they could squat poorly and actually pull it together and have a good landing because they used plyometrics. There are too many variables here. We can’t just assume a bad squat is a bad landing or vice versa.
But where should we start?
Listen to the neurological principles—the developmental milestones.
If the squat is out, don’t load it. Don’t put weight on top of it. Don’t put four-bodyweight velocity on top of it. All you will do is create a situation where the system gets good at compensating at higher and higher levels—probably at the expense of some structure and the deterioration of some function.
I’m not going to tell you where I got this video, but I can tell you it was shot of a 16-year-old female athlete who had her ACL reconstructed. This video was taken the day following release by her surgeon and her therapist. They’re not bad people—they just don’t have a standard operating procedure. They rehabbed her knee, but they didn’t rehab her.
The left knee was the one that was reconstructed—not the right.
We have a medical center in the States that polices itself. Independently, every one of their discharges goes through a biomechanics lab, and we scrutinize the standard operating procedure.
This patient had her second ACL surgery nine months after this video was taken and the behavioral pattern is still there. The structure was replaced, not the movement pattern.
A quick side bar…Back in the 1930s and 40s, aviation was not a safe profession. Lots of people died. Lots of equipment was lost. In one year, they completely changed the statistics. There’s a book called The Checklist Manifesto. Read it. There’s a book called Blunder. There’s a book called Why We Make Mistakes.
These books are about us. They’re about people who are highly specialized professionals who get in a mindset and don’t think outside the box. Not being able to think outside the box makes us perpetuate. We should have put a dent in low back pain by now and we should have put a dent in the female ACL epidemic by now.
We’re seeking better treatments instead of being proactive and finding out who’s already at risk. That’s where our mistake was.
Guess what the aviation profession did that completely changed its statistics for fatality? Standard operating procedure in the cockpit. That was it.
No extra continuing education for pilots and no new upgrades on equipment. They added a frigging clipboard to the cockpit—a mind-numbing checklist. Many people consider our work mind-numbing. These checklists for movement are mind-numbing, and yet they keep us on a baseline. That’s the one piece of consistent feedback we need.
Look at squatting across a lifespan. Is this supposed to happen? Does the lack of squatting have more to do with the cultural perception of squatting, or your lower body biomechanics? Get your passport stamped a little bit as you go around the world. If you go to a culture without plumbing, you will see a lot more squats.
We have to start looking at these movement patterns across a lifespan, but guess what we do? The minute we get a consistent screen to go across a lifespan, what do we start doing? We’re such empathetic clinicians, here’s what we do. We try to jigger the screen so kids and old people don’t have to do the same things.
Do kids and old people get the same blood pressure cuff? When we have older people read an eye chart, do they get these big-ass numbers and letters, or do they have to read the same damn eye chart that says we have 20-20 vision? If you can’t see, I want to know it. It doesn’t mean that you’re a bad person. It just means, let’s get you some glasses before you drive.
We’re establishing competency. There are certain things that happen to movement—habits, injuries and other lifestyle issues—that cause movement competency to dip below a functional level. When it does, you’re at risk.
At one point we tried to find one movement like the squat or forward bending. We were stupid there, too. We need a movement profile.
When I’m trying to type your personality to decide whether you’re an introvert or extrovert, I need about 40 questions to do it. Eighty questions will help me do it better.
Why are we looking at one movement pattern? Why are we just looking at single-leg stance? Let’s throw some movements together, and let’s do some intentional redundancy. Let’s have you get into hip flexion three different ways, loaded and unloaded. Let’s have you use your ankle loaded a couple of different ways.
Let’s have you do asymmetrical movement patterns—not obsessing over why you’re flunking the test, just simply saying, ‘Your movement profile falls below the cut. You’re at risk for your level. Let’s do something about it.’
This low squat used to be a preferred shooting position in the United States military, but now it’s no longer done. Was it because it was ineffective? Absolutely not. That’s one of the best shooting positions to be in. You can go from a big target to a small target very, very quickly.
A little bit after Korea, a bunch of boys showed up who couldn’t squat anymore. So what did we do? We deleted the position. But we have a lot of people shooting back at us who can still do that deep squat.
My problem—I simply needed to look at movement patterns in a standardized way, uncomplicated by impairment measurements, performance and skill. I had to look at movement competency, not looking at single-leg stance clinically, but looking at it as an epidemiologist would.
In medicine and in dentistry, they can do yearly physicals or so something to help you out because it’s been established that they can find signs…hopefully before you present with symptoms. I would like to invert our model as well, but it means that briefly we can’t think like clinicians.
We can’t bring our preferred manual therapy assessment to somebody who doesn’t have symptoms. Even though your manual therapy assessment might work for a person with symptoms, you’re going to statistically find more false positives than meaningful biomarkers that actually measure across a lifespan. Once people are hurt, you’re doing the right thing.
But when we’re working with normals, we have to accept a different platform. The platform we use is the Functional Movement Screen.
It takes about 10 minutes to administer. We’ve tried to pare it down, and every time we do we lose meaningful data. As soon as physical therapists learn that, they balk at the time requirement. But, look, you’re going to use it clinically at discharge for people going back to active scenarios.
What you need to do is get out in the community. Make sure every triathlon club, every firehouse, every high school and every local gym knows this system. Help people get certified. If you can get certified in CPR, you can administer this test. It doesn’t require a kinesiology background.
Here’s what happens.
We have an ordinal scale. A ‘3’ means you can do the pattern. A ‘2’ means you do the pattern with some degree of compensation. It’s not perfect, but it’s acceptable. A ‘1’ means you can’t do the pattern, and ‘0’ means you have pain on the pattern.
We’ve spent the last 15 years going around the States helping physical education teachers, personal trainers and strength coaches understand when they have somebody with a ‘0,’ meaning pain is onboard, motor responses are inconsistent and unpredictable.
What this means is exercise doesn’t work when people are in pain.
Motor learning is inefficient at best when you’re in pain. You’re better off not seeking a fitness solution to a medical problem. Twenty percent of the people going out for sports, showing up at a gym or trying to play professional football are going to have pain on the Functional Movement Screen even when they can pass a physical.
To do the screening, you don’t have to have a goniometer. You don’t need bioelectric sensors. You don’t need the force plate. What you’re going to do is to group people.
These people will become your referral sources. Increasing your non-medical referrals and stepping into the fitness population, the physical education population and the sporting population—showing people you have a viable tool—not only helps them rehabilitate injuries, but it also measures risk and deals with injuries before they happen.
Never thought of manual therapy before you’re hurting? We’re doing medication to manage your blood numbers before you’re to manage your blood numbers. Why not? We have to establish that. This is the first way to do that.
There’s been a lot of scrutiny of the Functional Movement Screen. I’m not a researcher. I’m just a clinician who felt I could do better. We’ve established some reliability with the screen. We’ve established pretty good validity as far as injury prediction. We’ve also demonstrated that it’s modifiable.
It’s reliable. It’s meaningful and it’s modifiable.
It’s a GPS. It tells us what to do with a movement profile. I’m not naïve. I am absolutely sure within my lifetime somebody is going to figure out a better movement screen. But until we have a GPS, we have a compass that seems to work.
We’ve had a lot of people throw stones at it. The only time they’re disappointed is when they ask it to be a clinical assessment or a performance test. We already have clinical assessments and performance tests. We just needed a movement profile to predict risk.
We’ve also done movement screens across a lifespan. One thing that astonishes me is that all of these people are participating in fitness at least one day a week. That’s how the movement screen declines across the age spectrum. Female athletes after the initial knee injury, whether they’re surgical or non-surgical, screen at or below the level of a 60-year-old female. Somebody is not treating these kids. Somebody is treating these kid’s knees. That’s really not acceptable.
That person has probably exited my clinic without being measured because I didn’t look at a screen on somebody with a neck problem. I might not have looked at it on somebody with a bunion or TMJ. But regardless of the diagnosis, running people through a standard operating procedure on exit will tell us how to give them meaningful advice. Whether they accept it or not isn’t your problem, but not giving it when you know better is.
I’ve spent all of this time talking about the Functional Movement Screen, which is a non-medical system. The Selective Functional Movement Assessment is a medical system. The line is pain—the minute someone has pain, we draw the line.
Many of you won’t be able to do this movement assessment on intake. Somebody might be too acute, too fearful, too symptomatic or too distressed, but if you do this before you start thinking exercise prescription, it will guide what you do. The way it does this is to use some words creatively.
In movement screening, we want an ordinal scale. We want to apply numeric value to non-painful people to categorize and group them for movement risk. However, once someone is in pain, it becomes an individual situation.
It’s not important how high they score on the screen if they have pain. I’ll tell you why. It’s because I’m not smart enough to answer this simple question: Are they in pain because they’re moving poorly or are they moving poorly because they’re in pain?
I can’t answer that question so I have to separate it. By creating a category of movement, not a score of movement, we can basically say, ‘Forward bending is functional and non-painful. Backward bending is functional, yet painful.’
That’s a marker. There’s no exercise they need to do for spinal extension. They showed you full range of motion, but it was symptomatic.
Often we see the freshman mistake in the clinic. A clinician will find a painful movement and give an exercise in that pattern. You ask, ‘Why are you doing that?’ The clinician might say, ‘We’re not going into pain. We’re just doing half-range of motion.’
I’m telling you, if the biomechanics are bad enough to cause pain at the end range, they’re already off at the beginning or initiation of the motor program. Don’t even mess with the pattern if there’s pain at the end of it. Treat it, but don’t ask them to exercise because the pain memory is there before the pain signal comes. They’re going to be screwing up extension exercises no matter how well you teach them.
But if we see a dysfunctional, non-painful single-leg stance, we can start attacking that right away and make a meaningful difference. That may or may not relate to the symptoms, but it doesn’t matter. If it’s a risk factor, maybe it is contributing with regional interdependence, but if it’s not, we’re still taking off a risk factor we’re going to have to deal with at discharge.
If you separate movement patterns, what you’re going to find is your exercise attacks are going to be on that green light right there—dysfunctional non-painful patterns. Your chance of increasing the symptoms is far less, and it frees up your hands to deal with the painful patterns.
We don’t exercise local kinesiology. We attack dysfunctional patterns.
Even though I’m heavily invested in my manual therapy education, they banged into my head at the University of Miami that I needed to know my neurodevelopmental sequence and understand why we were doing patterning and PNF.
If I don’t completely embrace why I should do something to someone’s spine and maybe put that person on a mat and look at some rolling, quadruped or half-kneeling first, I’m missing something. I’m assuming there’s a fitness issue with local kinesiology.
As a strength coach, we know this: The first four to six weeks of a new pattern, you’ve just learned how to do split-squats or you’ve just learned how to do walking lunges, that’s when you’re going to have your greatest strength gain if you train right. Yet, if we do a biopsy of muscle tissue at the end of that great spike in strength, we won’t be able to find any physiological evidence of changed tissue.
Structure didn’t change. What changed? The neural factors, the function did.
Now, none of us have time in the clinic to change tissue structure. There’s just not time. If most of your treatment cycles are within four to six weeks, if the patient makes a strength gain, let’s call it de-inhibition, or improved timing and coordination, or let’s call it more qualitative motor control.
If we’re banking on motor control, we have to follow a neurodevelopmental model—not a kinesiological model. That works for bodybuilding over months, but it doesn’t work in three visits.
Standard operating procedure is the first order to getting what I would consider a yearly musculoskeletal physical, but here’s the thing. I’m not telling you how to treat. I’m not telling you how to treat.
At the beginning and end of what we do, we should all agree on a standard operating procedure.
What you do between that demonstrates your individual expertise. I’m not telling you how to fly the plane. I’m telling you what to check off before you go. I’m telling you what to double-check. I’m telling you what to get your colleagues to double-check for you.
That kind of brutal objectivity and honesty is what The Checklist Manifesto is all about. It was written by a surgeon who talks about all of the blunders and mistakes surgeons make. It’s the low-hanging fruit, the little mistakes, the simple ignoring of the checklist that causes those.
We’ve been warned. I don’t know if we listened, but basically every expert clinician I’ve worked under has done something that’s impressed me. It’s not so much the skill of what they do, but they just have this intuition—this sixth sense. Malcolm Gladwell talks about it in the book Blink. They have advanced pattern recognition.
All we’re trying to do with a standard operating procedure is to tap into that. If you clean up patients impairments and they don’t move a bit better, you can get paid, but you didn’t change the functional platform.
The checklist we have to run through is this: We have to identify faulty function and we have to change it.
Just remember this. The dentist isn’t checking to see if you brush. It’s an opportunity for a skilled person who looks for biomarkers to have access to you in order to prevent a greater intervention at another time. They’ve demonstrated it so effectively that most insurance will pay to have a dentist look in your mouth even when you’re asymptomatic.
I did my best between raising kids and deer hunting to write a book called Movement. It can be a communication device for you. Often we are attacking and doing the same job as many people in the fitness and sports world, but we don’t use the same semantics. They don’t appreciate what you do because they don’t understand it and don’t have a concept of it. You probably don’t appreciate what they do.
In this book, we exposed movement screening for exercise and rehabilitation professionals, and also movement assessment. We clearly told the exercise professionals where their lines are and which lines not to cross because of professional responsibility.
The work has been misinterpreted. Some people think we’re teaching non-medical people how to do musculoskeletal assessments. We’re not. We’re teaching them how to do screening, because if cardiac surgeons only knew how to do CPR, we wouldn’t be doing too well. We have to enable them to do tests that give us biomarkers so we can operate the way we need to operate, and have access to people who are injured but don’t know it yet.
This has been my simple approach. I am absolutely honored to be here and share this with you. I would love for you to scrutinize this information. My colleague, Dr. Kyle Kiesel, has killed himself referencing this material. We’re saying that many of the new concepts you’re learning about motor control are in here.
I would encourage you to build a screen yourself if you’d like, but don’t try to equal what we’ve accomplished. Make it better, or at least use the tool we have until you have something better. Often when we get new information, the first thing we want to do is tattoo it and make it ours.
There was nothing out there at the time that did anything like this. We did it by mistake. We did it to be better clinicians in our own backyard, and then we realized it had some significance elsewhere.
The question came out of the clinic. It has taken years to validate this approach and do the research. It doesn’t take the place of anything you do.
It’s one piece of additional information.
The other sessions recorded at IFOMPT 2012 are available for download, courtesy of the Canadian Physiotherapy Association, at the link below.
For commentary from people who where there, please visit the following links.