Selective Functional Movement Assessment (SFMA) Level 1 Course Review

By djpope

November 17, 2013

course review, Selective Functional Movement Assessment, SFMA

If you’ve been following this site for any period of time you’ll know that I’m a big fan of Gray Cook’s concepts.  I’ve been using the functional movement screen (FMS) since 2006 and even wrote a big research review of the available research for the screen that you can find HERE:

That being said, I’ve been waiting to take the medical professional version of the FMS known as the selective functional movement assessment (SFMA) for the past 5 years or so.  The SFMA is meant to serve as a diagnostic tool used by medical professionals to find faulty movement and better direct treatments.

I’ve been finding a bit of controversy about the SFMA online lately and I’m glad that people are challenging the system.  I think it is important to stay critical but also to stay open minded to new ideas as they emerge.  Most of the comments I read have been based in a lack of understanding for what the SFMA truly represents and was created for.   I wanted to create this review to shed some light on the system as well as to give some honest feedback about my experience.

For the past few weeks I’ve been able to apply the SFMA in my clinical practice and I feel like I’m really getting benefit from it.   Here are some positives and negatives I’ve taken away from the SFMA and also how the system has helped my clinical practice as a new physical therapist.

The Pros:

1) A more in depth and systematic way to find biomechanical faults and quickly apply specific interventions

  • The SFMA presents a great way to make sure you dot all of your i’s and cross all of your t’s with your initial evaluation.  We aren’t going in and guessing what might be wrong, we’re systematically ruling things in and out.
  • My perspective and personal experience: As a new therapist this is very useful in guiding my evaluation because it can quickly hone in on the important issues and rule out what isn’t as important.  This systematic approach has made me more thorough and consistent from patient to patient.

2) A standard for diagnosis in the rehabilitation world.

  • Kyle Kiesel was the presenter at our course and was comparing therapy to cardiology.  If you go to several different cardiologists there is a standard operating procedure and most cardiologists will tend to come to similar conclusions on diagnosis with the same patient.  We don’t really have this in the therapy world.   Standard operating procedure tends to change based on the therapist.  This isn’t saying that the SFMA has to be the gold standard in the field but the SFMA can certainly serve the purpose of getting therapists on the same page when it comes to identifying movement deficiencies.
  • My perspective and personal experience: In our facility, speaking the language of the SFMA has been very beneficial when sharing patients among therapists.  It makes it very easy to figure out what needs to be addressed when working with a new patient evaluated by another therapist.  

3) The SFMA serves as a system to begin recognizing regional interdependence

  • In the therapy world we’re starting to realize more and more how injury and pain at one joint can be caused by a deficiency in a muscle or joint far from the painful tissue.  The SFMA gives a lot of valuable information about how the entire body moves.  You can use this information to determine whether or not you want to direct your treatment toward other parts of the body you feel may be responsible for the pain.
  • My perspective and personal experience:  It does seem far fetched that a problem at the ankle can effect the shoulder.  Certainly we know that issues at the knee (patellofemoral pain syndrome) and ankle (chronic ankle instability) can be associated with deficiencies at the hip and core.  Personally I find a ton of issues with the overhead squat that come from limited ankle dorsiflexion and a subsequent compensation at the shoulder in order to complete the lift.   With this in mind I can easily see how these two areas are related and should be addressed with treatment.  Kyle (SFMA presenter) never made the statement that these seemingly far removed movement problems were definitively related.  However, having this information definitely helps me as a clinician dig deeper into the issue and use my own clinical judgement as to whether these issues are related and how I should direct  treatment.

4) The ability to apply much more specific interventions for your patient

  • Given that the SFMA systematically rules in or rules out specific problems, you can use much less of a shotgun approach with your interventions and target what was found with the evaluation.
  • My perspective and personal experience: If I have a patient with mechanical neck pain that comes into my clinic I’ll most likely place them into a subgroup based on clinical prediction rules and my interventions will follow typical treatment for that subgroup.  My patient will most likely get some sort of thoracic spine/cervical mobility as well as strength and endurance training.  Depending on the patient’s mechanism of injury, chronicity of symptoms and FABQ scores they may get some pain education as well.  What the SFMA does for me is to help figure out what we need to focus on from a mobility/stability standpoint.  ie: Do we need more mobility?  Is it more of a stability and motor control issue?  Is my mobility deficit coming from the upper vs lower cervical spine?  Am I lacking thoracic spine extension mostly? or is rotation the biggest issue?  (Side Note: I know this isn’t as evidence based given that outcomes are similar for treating neck pain regardless of the type of mobility/strengthening exercises we use.)

5) The SFMA values breathing as an intervention and diagnostic tool

  • The SFMA places breathing as a high priority in treating and assessing movement dysfunction and pain.
  • My perspective and personal experience:  I’ve always had difficulty placing breathing interventions into my patient’s plan of care.  The SFMA has helped me identify patients who would benefit from breathing.  If a patient can complete one of the SFMA tests but holds their breath or tenses up in order to accomplish the task we would score that as dysfunctional.  What I have been doing is incorporating diaphragmatic breathing with a longer exhalation into my stretches and during ther-ex to get the body to relax a bit, gain new range of motion and improve the ease of performing that motion.

6) The SFMA does not require you to completely change the way you treat patients

  • The SFMA does not force an entirely new set of treatments to be used with your patients.  It simply hones in your diagnostic skills so that you can be more targeted with your interventions.   If you like to needle, then go ahead and needle, if you like IASTM, then go for it.
  • My perspective and personal experience:  I still continue to use all of the same manual techniques and exercises with my patients (although the SFMA has definitely opened me up to using some new interventions)  however I feel like I’m much more specific with my treatments now.   I also feel that I have more time to treat some of the regional interdependence issues I find because I’m much more specific and efficient with my initial interventions.

7) The SFMA gives an easy test and re-test approach

  • Patients can see an immediate improvement in their motion following a given intervention by re-testing using some of the SFMA top-tier tests or breakout tests.
  • My perspective and personal experience:  My patients really like seeing an immediate change in their ability to perform a given motion after some type of intervention.  This has really helped with patient buy-in.   I also feel like the nature of the SFMA requires frequent testing and re-testing to see progress and guide treatment which is always a helpful skill in physical therapy. (Anyone remember the HOAC model?)

8) The SFMA is great for athletes

  • My perspective and personal experience:  This is a personal opinion but I tend to think that athletes usually have more biomechanical faults that lend to pain and injury when compared to the general population (which might be more attributed to factors like central sensitivity and psychological issues – again this isn’t always the case, just what I see on a daily basis).  The idea of regional interdependence interventions really shines in this population

9) The SFMA is beneficial for individuals without pain

  • My perspective and personal experience:  Just as I came to the conclusion that the FMS can be useful for individuals with pain (so therapists can get an idea of how patients move even if they have faulty movement due to pain) the SFMA can be useful in patients without pain.  For example, if I run a crossfit athlete through the SFMA who has a terrible looking overhead squat and find some major thoracic spine/ankle mobility restrictions I can give a targeted corrective program to fix those issues (As opposed to blasting them with a thousand hip mobility and shoulder mobility exercises)

The Cons:

1) The SFMA is based in research but there is not much research out there about the system specifically

  • Just because something hasn’t been well researched doesn’t make it a poor system (God knows I’ve made up several of my own screens and assessments), but I would like to see some future research about the system (intra/interrater reliability, normative values etc).  I believe these values are actually being determined as we speak. (I consented to be part of a large study for SFMA normative values at the seminar)

2)  Long breakouts for each test top tier test with multiple flowcharts

  • Given that the SFMA is so thorough it can also be a bit challenging to learn to use.  The breakouts initially appear quite intimidating and you really do have to get the progressions down to be efficient with them in clinic
  • My perspective and personal experience:  I’ve been lucky to have some excellent mentors press me to learn and use the system.  I feel that it would be very easy to put the SFMA manual in the corner and never use any of the breakouts.  The whole purpose is that using the breakouts is vital to successful diagnosis.  I’ve been going over a new breakout every day and using them as much as possible in clinic and it really is getting very easy (and surprisingly efficient) to implement the system.  I feel that any time lost with diagnosis is made up easily with more targeted treatment.  I really feel that the extra work it has taken me to learn the system has paid dividends in clinical practice.  Also, understanding the principles of the SFMA will go a long way in getting toward an accurate diagnosis even if you’re having trouble getting the breakouts down.

3) The SFMA can be challenging to use in the geriatric and neuro populations.

  • The SFMA requires patients to quickly move from position to position (standing, seated, supine, prone on the floor etc.) which can be difficult with very painful or immobile patients.  What was a fast test for a healthy mobile individual seems to become a colossal task for an immobile patient.
  • My perspective and personal experience:  My question for those who don’t do some type of movement analysis for immobile patients would be, what the heck are you doing?  Figuring out movement deficits for immobile patients is crucial.  It may end up being partial breakouts, or multiple days of eval (which I agree can be very tedious, but ultimately very fruitful) but I’ve found that in the elderly population there are a myriad of things I find very quickly and have no shortage of things to treat to make these patients more functional.  Another con I’ve noticed is that it can be very challenging working with several patients at a time given that certain individuals will need guarding and extra attention throughout their session.   (Especially since I can’t consciously just give these patients heat and stim and feel good about myself at the end of the day.  Keep in mind this was something I struggled with before learning the SFMA too).  

4) The SFMA takes more time to perform on the front end

  • Performing an entire SFMA with breakouts can be very time consuming and can take time away from treatment time.
  • My perspective and personal experience:  As stated earlier, I feel that the time taken to accurately diagnose is well worth the ability to accurately deliver treatments.  I also find myself treating while halfway through a breakout frequently, making it a smooth and fluid transition.  For example, if I’m breaking out someone’s cervical spine and find an OA mobility restriction I’ll immediately perform a few mobilizations for that area and 2 minutes later the entire cervical spine is moving better.  Kyle also stated that he bills the SFMA assessment as ther-ex so you don’t end up losing money while performing the assessment anyway.

5) The SFMA is not an approach to decrease pain specifically

  • The SFMA is not a tool to treat pain.  If pain is found then you can use whatever modalities/therapies you have in your tool box to get rid of that pain.  A major principle of the SFMA is not to exercise painful patterns.
  • My perspective and personal experience:  I’ve heard some point out that the SFMA does not treat the painful source or somehow ignores pain.  This isn’t really the case.  The SFMA creators just make the case that pain changes motor control and then trying to perform painful exercise may alter that pattern for the worse.  Also keep in mind the idea of regional interdependence.  If the cervical spine is painful but we can exercise the thoracic spine without pain then we may be addressing the true cause of the pain (especially if the thoracic spine is dysfunctional, which the SFMA will have you looking at).  This is the beauty of the SFMA in my eyes.  You don’t have to adopt the treatment methodologies that other SFMA practitioners use, but now you are armed with more information to treat as you see fit.  

6) The level 1 SFMA course doesn’t teach corrective exercise strategy until level 2

  • Sorry, but if you really want to learn how to fix the issues found in the SFMA, you’ll have to pay for the second course.
  • My perspective and personal experience:  I understand that given the immense amount of material included in the SFMA it wouldn’t make sense to jam two courses into one weekend.  I’m a week out from the SFMA course and I definitely don’t have all of the breakouts down pat and dont’ feel comfortable going quickly through an eval on every type of individual yet.  I understand that this takes time and I’m happy to use the system a bit more before learning the correctives.  On the other hand I do end up finding certain things with the SFMA that I’m often at a loss to treat.  It really forces me to use creativity, but I’d also be happier if I could just plug in a treatment designed to help with a given finding and then move on.  At the end of the day it just forces me to become a better clinician.

7) The SFMA utilizes 7 top tier movements meant to best reflect daily movement

  • I’ve heard several people criticize the top tier tests used in the SFMA.  Do these 7 tests truly represent the best human movements we need to be concerned about?  Are there better movements?
  • My perspective and personal experience:  Really, I can’t say.  One thing I will say is that I personally feel that the SFMA is not a substitute for analyzing the motions a patient wants to improve upon or believes is causing them pain.  (ie: I still want to watch someone squat/snatch/clean on top of performing an SFMA if they want to get back to lifting)  On top of that I don’t know that fixing one of the breakouts within the SFMA will mean you’ll automatically improvement your daily activities (weightlifting, running etc.).  Given what we know about motor learning we’ll still have to implement these improvements into our activities and practice them.   I will say that I don’t know of another system that is as complete or attempts to break down movement as thoroughly as the SFMA.

Overall Impressions:

Overall I really enjoyed the SFMA course.  I am very lucky to be in a clinic that really supports the system and to have a few friends that have been extremely helpful along the way.  I can very easily see how you can go through the course and then throw the manual in the corner and never use the principles clinically.  It’s a ton of information that’s going to require some diligence in implementing into your daily practice.  It’s not a course where you learn a few tips and tricks for treatment.  It’s a bit of an overhaul for the way you practice but it’s been a fun challenge to put it into work.

I really enjoyed the presenter Kyle Kiesel.  As a short side note Kyle was helpful in me finding my current job so I’m a bit biased (He’s a good person and very passionate about his work).  I feel that Kyle is much more into the evidence based orthopedic side of physical therapy whereas Gray Cook is more into the philosophy of things (This is not a slam on Mr. Cook).  I’m a big fan of research based practice and Kyle runs most of the research for the FMS.  Needless to say I have a lot of respect for and trust in Kyle. (Kyle also continues to practice as well as research, teach and present seminars.  Busy man.)  I enjoyed the way he presented the information.  By the end of the seminar I was very excited about using the system but didn’t feel as if I was being “sold”.

If you’re on the fence about taking the course, I’d highly recommend it.  Then again I’m certainly biased but oh well, you’ll just have to take my word for it!

I think I was about 75% dysfunctional non-painful with my SFMA score,

Dan Pope DPT, CSCS