The purpose of a systematic approach is so you don’t miss anything.
1. When performing the SFMA, should the local impairment exams (ROM, MMT, special tests, joint mobility, etc) be included at the terminal point of the most dysfunctional, non-painful (DN) pattern or at the functional, painful (FP) pattern?
The most important piece to consider here is that the SFMA does not usurp anything you want to do, like to do, or feel confident in doing. It is an adjunct and an organizer of sorts for the methods that you and your team can employ for painful patterns, stiff patterns, non-purposeful patterns, and under-capacitated patterns. Local impairments still serve your purposes, perhaps now with better perspective.
I can say that wherever you plan to retest, any objective measure you have can be audited. I am not sure what the latest company line is on this in terms of when to use local tests and when not to, but I would say one reason to do it at the FP could be honor the traditionalism of how documentation is reviewed. That reason has very little resonance with me, but I could see where that can be warranted in many settings.
To redirect towards systematic principles in evaluation, I think the only things that need to be measured are the ones that will either help us make a decision in using a method or to confirm that a purposeful measure has or has not been restored.
To address each of the local measures……,
ROM as measured by the reliable positions often leaves us with a position that is not purposeful. I am very happy with my ROM oculometer readings.
MMT is useful in an ill-performing segment or a purposeful one, however this has nothing to do with strength. In a compromised joint system, MMT can not measure strength. It can measure the system’s allowance of force production, but a “weak” MMT score in no way, shape, or form should take you to a strengthening exercises especially when there is pain. It’s closer to a screen or test to take you to further tests and methods.
Special Tests really have no use in my mind, particularly if pain has already been identified.
Joint Mobility tests will be very useful when a JMD is apparent or if a joint mobilization drill is indicated in your treatment approach. Certain joint drills can be very useful for non-JMDs.
2. Do others typically break down the FP patterns to determine at what level the patient’s pain exists (NWB vs. WB)? I noticed in the text that the most DN and FP patterns are recommended to be broken down.
I think you could, but again, I don’t know the latest company line here, or if it’s firm.
In an FP, there is such a likelihood of running into a red box where you either wind up treating locally or ignoring it and training the DN, so I don’t know how enlightening a breakout will be. At least that is my experience.
Unless you’re seeing a very confusing system, I will not break out the FP. What I will do is run a treatment model that has some other local or fascial evaluation points to best guide treatment. Or even more likely where I am seeing someone in 1-and-done situation, I will treat the pain to instill confidence, demonstrate the person is not doomed, and insist they should continue with their primary clinician or trainer to fill in the gaps that will really make a difference long-term.
Running such models as Fascial Manipulation, local manual therapies, or DNS won’t necessarily speak to the breakouts, but as I describe it, they may “pull the cloak off” the system and show a more authentic motor presentation with less threat.
And then all or some of the breakouts will look very differently. This doesn’t suggest that treating the pain is the answer, but aside from instilling confidence in a new patient, it can offer clarity in more significant direction in treatment.
3. What are the implications if one receives a FN in the upper extermity patterns, but has a (+) clearing test (Yocum or crossover). Should one proceed with corrective exercise, since pain exists with a clearing test, but not with the movement itself?
Rule #1 – Ensure pain is not medical. If a directed motion causes a painful response, it is likely not medical.
Rule #2 – Ensure pain is not orthopedic. Unless you can order imaging, there is no great way to get closer to confirming this. It may not be significant, but I am not so cavalier to think surgery is never warranted, nor should a proper team-based surgeon’s set of eyes be brought in.
Rule #3 – Train around the painful segment.
Rule #4 – Change the compromised or non-purposeful (for further adaptation) segment.
In this case, with a motor skill approach, you would likely land in Supine Reciprocal Upper Extremity as long as it was non-painful. You can’t keep trying a “corrective” if it causes pain. Far too often “contemporary” approaches lead us away from remembering that painful segments may actually be chemically-mediated or have wild structural lesions that conservative measures will not affect. SMCD approaches should be successful quickly.
Other options include medication/injection and review the evaluation. This would still land as an SMCD and fascial treatment approach.
You run a SNAGS and see if it affects the FP. You could run a trigger point or Fascial Manipulation treatment.
Perhaps most importantly is the be confident that the cervical spine is not affecting this from a referral (TrP), radiation (McKenzie), or other neuromuscular (Mulligan, Maitland, Paris, Dunning) context.
4. During the FMS, doesn’t one go after all asymmetries first? For example, a hurdle step with a 2-3 score would be before a ASLR with a 1-1 score?
The current suggested FMS corrective algorithm doe not take into account symmetry. The same order is employed: ASLR, SM, RS, TSPU, ILL, HS, DS. Until the ASLR is a 2-2 or 3-3, then you do not move on. Asymmetries will be taken care of, but it will streamline decisions.
In the case you describe, the older model and the current model would still take you to ASLR.
Level 2 FMS will have new slides that best describe what is suggested.
And in my opinion, once you very strongly understand what is commercially suggested, you can go off the reservation as long as you do one thing.
Just make it happen.