Purpose: To provide a very selective review of Charlie Weingroff's course and how it actually fits with a neurocentric view of pain and function. Audience: Therapists and strength coaches. Patients who have trouble sleeping.
1. Jeff Cubos discusses SFMA, DNS and Lorimer Moseley and they inform his practice style
I took 2 days out of Charlie Weingroff's course, Training = Rehab, Rehab = Training course here in Toronto from MSK-Plus. MSK-Plus is a continuing education company run by Dr. Glen Harris. Dr. Harris has brought in a lot of great educators over the years and this course was not an exception.
WARNING: I missed the first highly practical day of this course so don't see this review as some massive summary. This review is not meant to be extensive or an advertorial. Ideally, it will review some of the main points of Dr. Weingroff's teaching. Please view this summary as my interpretation. Much of the language I use will be in my vernacular and should not be attributed to Dr. Weingroff or those that have influenced the content of the course (Gray Cook with the FMS and SFMA and Dynamic Neuromuscular Stabilization).
What is in this long review? So long that it needs a table of contents!
- A bullet point summary of my interpretation of the key points of Dr. Weingroff's approach to treating injuries and pain
- Review of how the Selective Functional Movement Assessment (SFMA) works
- A brief review of a case study
- My thoughts
- Constructive criticism and reservations of the approach (hurdles for my brain)
- Comments on the Educational Effectiveness
- Final Thoughts
Summary of the key points
- Dr Weingroff was teaching a system of evaluation. He uses the Selective Functional Movement Assessment (SFMA) developed by the folks at Functional Movement Systems (of FMS fame). A very detailed introduction to this is Gray Cook's book, Movement.
- Charlie uses the SFMA to help direct his treatment. The treatment that you use can be unique to you. The treatment is any "tool" you choose and the SFMA helps you prioritize where or what you should treat
- SFMA is based on the assumption that there are ideal ways for humans to move. Deviations from these ideals MAY be problematic. This assumption has always been a sticking point for me since I read Athletic Body in Balance more than a decade ago. I was always concerned that users (or abusers more likely) of the SFMA would catastrophize and find problems that weren't really problems and then create a defeatist attitude in their patients. The "problems" they found would then only be able to be fixed by the "guru" they were seeing. I was pretty happy that after taking the course on the weekend this concern of my mind was changed.
- Remember, the SFMA is a system not a method of treatment. You can treat however you like. Charlie has personalized his use of the SFMA with his education in Dynamic Neuromuscular Stabilization aka. DNS (I don't know shit about this so I can't say much). He uses what he knows about DNS to help provide a rationalization for why he uses the SFMA and the interventions he chooses.
- Basically, DNS suggests that a growing human attains certain movement milestones (e.g. rolling, crawling, squatting, standing, walking, falling). In order to attain these milestones you need to have certain mobility and stability abilities. Big ones for DNS is joint centration (e.g. you centre your femur in your acetabulum via motor control of hip and spine muscles) of the hips, spine and shoulder. Charlie's assumption is that these are the foundational abilities that a human needs to move properly and the SFMA provides us with a screening tool to determine if we have those abilities (at least, thats how I saw it).
- Did I mention that you could choose any treatment you wanted.
- Charlie's goal is to treat people for as short a time possible
- Corrective exercise (to me, remedial and simple) is not a goal itself. Exercise should progress to high levels of loading. Patients can deadlift and this can be part of many rehab programs (I love this)
- Biomechanics takes a back seat to motor control
- Pain is not tolerated. Exercise should not hurt
- Pain is the perception of threat.
- Motor control in the presence of pain is not reliable (To me this is analogous to saying that biomechanical changes are associated with pain but not necessarily the cause. These are defenses and not defects. So just targeting these defenses may not be helpful)
- Your treatment intervention should address the movement that you found to be "Dysfunctional but non-painful (DN)
- Local treatment at the painful site is permitted (using whatever technique you think modulates pain) but in order for "ideal" resolution or the prevention of a future injury you should address the dysfunctional movement found on the SFMA.
- The SFMA is a framework or system that helps you eliminate what you should not do. It helps you focus your intervention. I believe other approaches would suggest that you are looking for a primary driver. This is a murky area considering the primary driver of some pain is just the brain after awhile. I think this might be an area (e.g. persistent pain, perhaps with a strong central component) that the SFMA would be less helpful. Although, I think I can actually make a case.
- Treatment should exist at the intersection between a "dysfunctional movement" and the anatomical source that might account for the nociception (Charlie said pain but I split hairs and say nociception).
- Therapists should thus know all of the possible sources of nociception for a given anatomical area (e.g. radiculopathy, "trigger points", sensitized nerves, joint referrals) and the anatomy/structure that can be involved with a movement considered less than ideal.
- A patient's ability to produce a movement is context specific. For example, someone might not be able to squat but when in quadruped they have the ability (or at least joint mobility capability) to attain all of the joint positions of the squat. They just can't do it under load. This would suggest that this is a motor control or stability issue. Charlie calls this the need for a "software fix".
- Building "capacity" (e.g. tolerance to stress, strength etc) follows after attaining capability of certain movements. They say "move well and enough" first.
- High threshold movement are abnormal and something that we might address. These are obviously inspired by the Queensland group and Bergmark's spine stability ideas. Basically, it is the idea that big, multisegment, global muscles take over for smaller, tonic, segmental muscles. The patient might have delay in the multifidus or tranny activation (we can't see this) and their big muscles take over to produce movement when they don't need to. This shows up as rigidity, lack of fluid movement, guarding etc. As a therapist who treats persistent pain, I would explain this kinesiophobia, fear of reinjury, stress and anxiety. Interestingly, my concern with the SFMA was that it might create these beliefs and this type of movement in patients. The way it was presented to me is that we want to avoid this and our treatment can empower patients. (my words, not Charlie's)
Brief explanation of the SFMA
The SFMA is seven screening tests. Each test only tells you if the patient can perform the movement or not and whether they have pain or not. It does not tell you where a problem is. Thus, if you think there is a problem you have to follow up with more tests. After performing a test you have four possible results:
FN: Functional and no pain (Yaaa, they did it according to certain standards with no pain)
FP: Functional and painful: they did it but it hurt
DN: Dysfunctional and no pain: They could not do the movement but it did not hurt
DP: Dysfunctional and painful: They could not do it and it hurt
The seven movements (a pdf is here SFMA Score Sheets) that you have patients do are:
1. Multiple Segment Flexion (MSF) aka:
2. Multiple Segment Extension (MSE)
3. Multiple Segment Rotation (MSR)
4. Cervical Pattern (Flexion, Extension, Rotation separately)
5. Single Leg Stance
6. Upper Extremity Patterns (Hand behind back and Hand behind head)
7. Deep Overhead Squat
with two provocation tests (cross body shoulder adduction and a shoulder impingement test)
After you run the patient through these tests and categorize each into one of the four categories the SFMA suggests that you ignore the painful movement for a bit. You don't actually ignore it though. You get to use it as a comparable sign or as part of your treatment audit. It was also suggested that your local treatment techniques can go after the painful area but this should not be an initial priority.
The initial priority is the DN (dysfunctional and non-painful). This is your safe window into treatment. Pain is all about the perception of threat. We don't want to scare that skitterish pain rabbit. We're gonna cook it but it doesn't have to know that yet.
If you have multiple DNs. You choose the one to work on based on the following hierarchy:
-address cervical spine dysfunction
- address asymmetries
- MSF, MRE/LRF, MSE, MSR, SLS, Sq
Brief Summary of the Case Study
The patient was a male sprinter with a recent history of right achilles tendon pain. MSF was Functional but Painful (FP) whereas Multisegment Extension appeared dysfunctional and non painful. There was some pain in the right AC joint during the provocative maneouvers although the range of motion of that region was greater than the other shoulder region as tested with the upper extremity movement tests. Single leg stance was FN and the deep squat was painful and dysfunctional (DP). I don't remember exactly what happened with the cervical testing (I did not think I was writing this article so I didn't take notes). Regardless, Dr. Weingroff focused on the multisegment extension test (dysfunctional and non-painful) as it appeared to be limited. Two breakout tests were performed:
1. Standing multisegment extension with one hip flexed
2. Prone lying spine extension coupled with rotation
These tests showed two things. A restriction in hip extension in the right leg during the first test and pain in the lumbar region when passive extension was coupled with rotation. Ankle dorsiflexion (CKC) was also assessed and found wanting on the right.
This prompted two more tests. Prone leg extension performed actively and passively. This test suggested that the patient had full passive hip extension (i.e. not a joint problem) but less hip extension when actively performed by the musculature (i.e. suggested to be a motor control problem).
And somewhere in this assessment Charlie did a Mulligan technique directed at the painful right shoulder. The technique involved a SNAG of C6 coupled with right shoulder crossbody adduction. The pain was decreased with this Mobilization with Movement. Thank you Brian Mulligan. I was happy to hear that the explanation for this pain modulation put the brain and nervous system as the modulating influence rather than some mechanical explanation at the level of the joint. I don't know how this fits in with the SFMA hierarchy. Sorry.
The treatment of the Non-Painful Dysfunction (DN)
Charlie suggested the primary dysfunction was a lack of hip extension due to a motor control dysfunction. Treatment consisted of the patient starting in a lunge pattern, pushing both hands into their front knee, squeezing their Gluteus Maximus and then doing some DNS based stuff. Charlie worked on having the patient change the position of their ribcage via their lumbar spine. I believe this involved activating the obliques to pull down on the ribcage and this would lead to a decrease in lordosis. I assume this was coupled with the glut max leading to a posterior pelvic tilt which would again decrease lordosis. Charlie did more than this which was based on DNS "joint centration" through the spine, hips and shoulders. The patient was encouraged to remain tall, slightly tuck the chin and breath through the diaphragm. I am not doing this justice so judge me not Charlie. Several repetitions of this occurred and then it was repeated with the lunge being directed 45 degrees laterally.
The comparable sign
The patient was then reassessed. The painful movement (MSF and prone extension with rotation) was reassessed as was the shoulder movement. Pain was reported to be less or gone and changes in shoulder ROM were noted. I didn't call the patient to see how they are today and I can't time travel so I don't know what they are like three weeks from now.
The goal is immediate change in symptoms. Dr. Weingroff (remember he is a powerlifter) calls this "one shot, one kill". As a gentler man I'd call it kissing the right girl. Which is the ultimate point of the approach (and certainly up for debate). It assumes we can find the most important "dysfunction" that is driving force behind the continuing pain.
My thoughts on the approach
I was quite surprised by the course and how the SFMA was used. My concern with the SFMA in the past was that it was a castrophizing monster that finds imperfections in movement (which I view as natural and healthy variability) which in turn creates "work" for the therapist. But, it does not have to be this way. The SFMA is not the catastrophising monster only the therapists who choose to abuse it.
My concerns in the past revolved around the idea that people need to have certain fundamental movement abilities. I still don't think that we can be so absolute about things. If your patient's hobbies are reading books and going for walks do they really need to be able to reach behind their back to solve their persistent pain? No one at this course was suggesting this. This to me indicates that some movement ability is task and population specific. This I can get behind.
For persistent pain I think the SFMA can be used as a framework. It shows you which movements are painful and which are not painful but their movement may not be "ideal". You then get that patient moving in that non-painful but less than ideal movement (i.e the DN). You help them increase their ability during this movement without creating any pain. This can empower them, build capacity and can be part of a graded motor activity program. It might have nothing to do with retraining a motor program or improving movement quality and more to do with decreasing fear, downregulating threat, increasing confidence and just helping the brain modulate pain. This is an example where the system can be effective but maybe not for the reasons we think.
Where this is less useful in persistent pain is that cranked up patient with a large central component where almost all movements hurt. Obviously we can't just treat the nonpainful movements because there aren't any. I'm also a little hesistant about not doing any movements that cause pain. I think it is OK for patients to have some pain when they move. This is why educate about pain neuroscience. We can't always let pain be our guide. Pushing the edge of pain can help increase the patients threshold for pain. They learn that pain does not equal injury and this can be empowering as well.
Constructive criticism and reservations of the approach (hurdles for my brain)
- the concept behind the SFMA is that there is an ideal way to move that is consistent across all individuals. This is still debatable to me. I think this is patient and context specific. Certain individuals certainly do need certain movements but I have reservations that this must be applied to every human.
- asymmetries are considered dysfunctional - again, very debatable. A lot of research on both sides and again may be context and individual specific. I suppose you have to draw a line in the sand and just pick a side. Or straddle!
- the assessments and breakout assessments are subjected to the same biomechanical questions and doubts of all assessments tests. For example, if you are testing the rotation of the spine it is assumed that if you flex your lower back this will stop rotation in the lower spine and isolate it to the thorax. This has been investigated and it does not look to be true. While there is a little less lumbar rotation than neutral it is not starkly different. Caveat - this is being a bit nitpicky.
- the concept of treating the non-painful dysfunction which in turn leads to less pain in the painful movement can be tested. Take two groups with "x" pain. In both of those groups find a non-painful dysfunction. In one of the groups treat this non-painful dysfunction. In the other group find a non-painful but functional movement pattern. Now train the crap out of that non-dysfunction and non-painful pattern. Both groups should also be told that you are treating a non-painful dysfunction. Compare for changes in pain after the intervention on the painful comparable sign (FP or DP). This simple experiment lets us know if there is something special about the "non-painful dysfunction" or if it is just the act of moving painfree, receiving attention, correction, co-ercion, interaction etc. You can do this study in the shortterm (e.g. after one session) or over the long term.
Comments on the Educational Effectiveness
This is more of a comment for every single CE course out there (myself included when I give brief lectures). I think in general courses need to give a little more material than just power point lectures. I don't think that anyone that ever takes a course should have to take notes. The courseware that comes with the course should be comprehensive and then some. You should never feel that you have forgotten something from a course. You should have material that you can reference years later. Again, hats off to the book Movement, which would serve as this reference material if you took the SFMA or FMS courses.
Now the positive. Charlie was great. He really took the time to answer (not just snowball) peoples questions. I also felt like he genuinely tried to make the course very practical for everyone. MSK-Plus also had extra senior clinicians (Chris Nentarz and Joe Heiler) to help with the participants.
Charlie stressed that the SFMA is a system. It does not tell you exactly how to treat but tries to give a comprehensive means of analyzing movement. You can then use your particular skills to treat in the manner you see fit. I like to think that practice using the best available evidence, founded in scientific plausibility and consistent with what we think we know about the science of pain. With only a few reservations, I felt that I can use the SFMA and still be true to my treatment approach. The goal of Charlie's course was not to get you to practice just like Charlie. It seemed to be suggesting a systematic approach to help you practice like a better version of what you might be doing now.