Optimize physical performance, innovate clinical practice

By: Ramez Antoun, PT, DPT – February 15, 2014
So the day started by having both Gray Cook and Dr. Stu McGill give their presentations. It was then followed by each of them doing a demo/screen on a gentleman from the crowd to practically highlight points they made in their presentations. Then time was given for questions and answers followed by concluding statements. craigstugray

Gray Cook started the day off by explaining the “why” behind the FMS. And simply it was a way from him early in his career as a PT and strength coach to set the bar for himself and his colleagues in terms of a movement quality minimum baseline that they tried to meet with every one of their patients/clients, and when they didn’t they would ask themselves why. Their goal here was to first look at and set a baseline for movement patterns first before obsessing over the individual parts. Back in the 90’s there was no means of measuring whole movement pattern quality. We were, and the majority of us still are, analyzing, measuring, and trying to fix parts and expecting the parts to work themselves out to produce a clean whole movement pattern.

We have screens for looking at blood pressure, hearing, and vision; and there is a minimum level of competency that you must demonstrate in each of those categories before you are cleared by a health professional, but when it comes to movement we never screen movement quality and we never had a means of looking at a minimum level of movement quality competency until the FMS. Gray explained that the FMS is simply a screen and nothing more than a screen. Many people try to turn the FMS into something it was never intended to be, it was NEVER meant to be an assessment or something that predicts the future. It was a way of looking at 7 basic patterns first and making sure we took pain (score of 0), significant dysfunction (score of 1), or significant asymmetries between right and left sides (1-3, 1-2) off the table first before loads and conditioning entered the picture. It was also never intended to police perfection of movement either, as long as you had no 1’s or 0’s or significant asymmetries “get on with it” he said, aka get strong and fit and if there is a 2-3 from left to right side address that during movement prep and workout. Just make sure you routinely go back and screening the person to make sure you’re program doesn’t make their baseline movement quality worse and/or create significant asymmetries.

The FMS is a means of getting an idea of someone’s prerequisite sensorimotor competency using their own body weight. He discussed how the FMS has intended redundancy built into it (for example to look at hip extension in 4 different patterns); if the motor outcome of a pattern is not ideal (i.e when the right hip is in extension) in one pattern (in-line lunge) but is fine in another (ASLR) there may not be an issue with the sensory input driving that pattern (aka mobility) but if there is a consist limitation of patterns that involve the right hip in extension then there may be a mobility (lack of sensory input) issue. This is an oversimplified example as to why the total score of the FMS DOES NOT MATTER because what really matters is the

individual scores of each pattern compared to left and right sides and comparing the 7 patterns to one another to possibly provide insight to a consistent issue in various positions.

Gray used a beautiful metaphor of taking everyone to a shooting range to train them how to shoot and assuming that everyone has perfect vision or had their glasses that day. Well what if you forgot your glasses that day, yet we still expected you to perform just as well as everyone else? How would you feel compared to your peers? Embarrassed? Inferior? At a disadvantage? How is that different than dropping an exercise program on someone assuming they have the prerequisite mobility and stability to execute the exercises efficiently? The FMS is a compass, it should give you direction as to what you can and maybe shouldn’t do just yet in your program (or what you should delete from your program for now) until you correct the dysfunction at a basic level first to set your clients up for success.

Gray said it himself, the FMS is not a catch all system its simply an entry point for movement pattern quality, a compass, and the day someone creates a better system he’ll be the first to embrace it, but for now this is the only systematic tool we got for quantifying the quality of movement patterns while providing our profession a means of efficiently communicating our findings with one another (given you understand the FMS terminology). Gray communicated openly that he knows that the FMS is not perfect and embraces professional criticism toward it in order to make it better.

So don’t get hung up on the total score (which unfortunately most of the research looks at) because the total score is NOT what gives you the insight and direction in terms of what not to do, what to do, and which patterns to attack first if several are not so good. My interpretation of Gray’s message was that you must pay the price of studying the actual system of the FMS and the principles that underlie its appropriate application and hierarchal organization rather than haphazardly and blindly throwing out correctives without revisiting what you intended on correcting in the first place. After you have done that and the system still doesn’t work for you, you’re not obligated to use it.

McGill brought in some very interesting research on the FMS most of which looked at total score (McGill respectfully emphasized Gray’s previous point that the total score does not really matter as much to him as the individual scores) and how even those with total scores much greater than 14 did not necessarily correlate to a low risk of injury from a statistical stand point. He brought up how other confounding variables such as the repetitive stress that players who get more playing time and/or play more involved positions are exposed to obviously may contribute to that player’s elevated risk for injury regardless of their FMS score. This same idea is applied to occupations that may require more repetitive stress and hours of exposure to that repetitive stress, firefighters were used in many of his studies. McGill really digs deep into the potential of the mechanism of injury and the technical execution of the movement that the individual is exposed to.

ramezmcgillMcGill also brought up how the restraints and rules of the FMS test doesn’t necessarily capture and demonstrate how people will naturally move in routine situations during activities of everyday life. In other words “just because they can, doesn’t mean they will”. Thus McGill finds it very important to also asses, as mentioned before, the way people naturally execute the movements they do during their sport, job, and everyday life (asses the way they walk in, the way they sit in the waiting room, the way they lay on the treatment table, how they take off and put on their shoes) to truly get an idea of the actual stresses exposed to their bodies in the context of their world and their specific situation. “It depends” was a common answer Dr. McGill gave to various questions because it is evident that he, as should everyone dealing with the human body, treats the whole person (physical, emotional, intellectual) utilizing their specific goals and their psychosocial situation to come up with an “in the moment” assessment specific to them. This is when Dr. McGill highlighted that this may be why it is difficult to teach his assessment style because unlike the FMS system it is not as systematic with a general direction, “it depends” on the individual that is in front of him and the context of the world they live in.

McGill brought up an interesting study that showed that simply just coaching certain individuals and telling them what they were getting testing on increased their FMS score. Sometimes people just need technical coaching rather than a complex corrective exercise algorithm to improve a pattern. Also one study showed that loading a bad pattern for some people (~30% of the subjects) was a corrective strategy and improved their score in that pattern, yet with the rest it served to make the pattern worse and lowered that pattern’s score. Dr. Phillip Snell’s review beautifully articulates how even a 3 on the deep squat of the FMS doesn’t necessarily give you the green light to load that pattern given the behavior of the lumbar spine during the movement.

One of my favorite stories that McGill shared with us is when he was brought together with Pavel Kolar, the mind behind DNS, to discuss their systems together. Apparently there were 3 different athletes that were brought in to be evaluated by each of them. While one was evaluating, the other was escorted out so that they weren’t allowed to see the other’s evaluation and vice versa. This was done 3 different times for all 3 athletes. To make a long story short at the end Dr. McGill and Dr. Kolar took two completely different approaches during the evaluations yet came to the same conclusion about each of the athletes at the end. McGill used this to emphasize that just because a system or an approach doesn’t work for you doesn’t mean it’s wrong, but you need to find what works for you and abide by your own set of principles to help those that come to you for guidance.

The demo was interesting because both Gray and McGill were given the chance to screen someone and bring their presentation to life if you will. So Gray was up first and he screened a gentleman that demonstrated no “0’s” or “1’s” and no significant asymmetries, basically clearing the person to “get on with it” and get loaded/work out, yet making sure whatever he goes and does, doesn’t bring him below his movement quality baseline. McGill took this same person checked his squat with no load and then assessed the way he pulled in a heavy rope (pretending he was a firefighter and testing him in the context of his goals/lifestyle) and disqualified him in less than 15 sec for technical failure of using his spine more than utilizing his hips to pull the rope in. By doing this McGill highlighted this individual’s potential mechanism of injury if he continues to execute this task in his life. To me both approaches did exactly what they were intended to do, Gray cleared basic movement pattern competency and McGill caught a potential mechanism for injury based on technical failure during a context specific movement pattern for that individual’s life requirements. You can’t have one without the other and both approaches are needed to provide a comprehensive screen.

To me there was not much disagreement at all during the entire day, both Gray Cook and McGill seemed to agree more often than not yet they were looking at screening/assessment a little differently. Gray Cook wants to screen/clear a basic level movement competency as an entry point for fitness and to catch red flags for movement inefficiency. Likewise, McGill also addresses basic movement patterns, but takes it a step further and looks at specific movements which the person is constantly exposed to and is set on finding their specific potential mechanism for injury with activities they are exposed to in order to guide and coach that person to become as resilient as possible. A great clinician/strength coach will utilize both mindsets to help give our patients/clients every piece of our professional ability and serve them the best we can. These two men demonstrated the utmost respect and gratitude for one another and clearly left Stanford with a much deeper professional bond and more importantly a deeper friendship with one another. McGill closed by telling us that he wanted to accomplish 3 things at Stanford and that was to provide people with some clinical tools, represent the scientific approach, and to do it with grace; and that he did.