Shirley Sahrmann, PT, PhD. is a world renowned physical therapist and house hold name in connection with movement system impairment syndromes (MSI). Shirley has been shaping the education system in the States for many decades and continues to be active as a clinician and teacher at Washington University. Shirley has also published two highly regarded textbooks on MSI: Diagnosis and treatment of movement impairment syndromes and Movement system impairment syndromes of the extremities, cervical and thoracic spines. I recently attended her lower quadrant course on MSI of the lumbar spine and the influences of, and relationship to the hip. This blog is an overview of the key messages I took away from the course.
Shirley Sahrmann - image sourced from Google Images.
WHAT I LEARNT ABOUT SHIRLEY SAHRMANN
Shirley is passionate about physical therapy, she is curious to always be learning and testing her knowledge, she has a very well tuned 'crap detector' and she laughs (all the time). Working with patient's in pain can be demanding and draining and it really stood out to me that while Shirley was serious about solving the problem at hand, she encouraged her patients/students to be relaxed and join in the laughter. She was engaging, funning and clearly a true expert. Shirley has been working in our profession for over 50 years. I can't begin to wonder how deep her knowledge of pattern recognition truly is and know for sure that I only saw a glimpse of it during the weekend. Like many experts I've previously met, Shirley shares a common moral trait and belief -she believes that to build up our profession you need to continue going back to the source. She continues to be involved in teaching and sharing her experience so openly, so that as a professional body we grow together. She still is striving towards the 2020 vision that we will be recognised as the profession that are experts in training movement disorders. For that I have so much respect.
ABOUT THE MOVEMENT SYSTEM APPROACH
The 2020 Vision of the APTA is to transform society by optimising movement in the human experience and the first principle of this vision is IDENTITY. Physical Therapists are not identified by what they know, but what they do and to improve our identity within society, we need to have a common language to unite our profession. The movement system was created to form a commonality in language regarding pattern recognition within the profession. As Shirley explained, 'we don't diagnose movement diseases but movement dysfunctions and therefore those dysfunctions need meaningful terms that people and practitioners can relate to like a diagnostic label'.
My personal experience is that in Australia our common language regarding dysfunctional movement comes from Specialist Physiotherapists such as Peter O'Sullivan, which is classification system for non-specific lower back pain I have not seen commonly used in the USA. But there is more than one classification systems that exists e.g. McKenzie, Mulligan and Janna are all recognised classification systems. Something that these classification systems have in common is that they are all movement based not patho-anatomical-tissue based. More that that, these systems consider the primary and contributing factors that are beyond musculoskeletal. It is not just our muscles and bones that make us move the way we do. Movement is a complex behavior within a specific context and Physios can provide an unique perspective about purposeful and precise movement. Having gone to this course to find out what Shirley's work is all about, I came away understanding how important it is now is for me to speak the same language and almost be bilingual between AUS and USA.
My one great fear is that we have been shrinking movement systems. McKenzie is known for extension biases, Mulligan for Snags and Nags, Maitland for manual therapy etc etc. but that is not purely what they did. These were all expert clinicians sharing their clinical knowledge for the management of movement abnormalities and over time the quality of their knowledge has been diluted and distilled to single beliefs that people can recognise them by, yet no longer truely represents the depth of knowledge that these clinicians possessed or what their movement systems were about. It will take much more than a 2 days course for me to understand the full depth of the MSI approach and the same can me said for other classification systems in our profession.
KEY LEARNING CONCEPTS
To understand how movement dysfunctions occur you need to first understand the concept of relative flexibility, relative stiffness, and motor learning. These are the factors that contribute to the development of using the path of least resistance for movement, but, as Shirley repeatedly emphasised, more efficient doesn't mean more effective. Using the MSI approach requires the following steps:
- Identify the cause of the dysfunction
- Identify the contributing factors (tissue and motor control)
- Organise specific tissue impairments
- Provide a direction for intervention
- Always make your decisions based about anatomy and kinesiology of normal and abnormal movement.
The course covered a huge amount of detail and went through case examples of each time of lumbar and hip MSI. Here are 10 key learning concepts that resonated with me.
- Know how to assess both accessory and physiological movement assessments as they provide different information about how joints move and are not interchangeable during assessment. The two things that create destruction are sheer and points of high contact pressure. Therefore, we need to be confident in assessing both the accessory and physiological movement.
- We need to understand the gritty detail of kinesiology before we can understand and integrate movement arms of muscle function for differing joint angles into our analysis of assessment. For example, understanding the movement arms of gluteals as the hip moves into flexion helps us understand why we might assess hip abduction in extension, external rotation strength in extension and medial rotation strength in flexion. If you don't already know these details, time to head back to the text books and revise your understanding of dynamic anatomy.
- The goal of assessment is to observe a patient’s preferred alignment/movement strategy and obtain a response. If there is an impairment, repeat the test with a modification (compression, decompression) and re-assess. From here you can decide if there is a structural limitation or if there is a functional muscle limitation/impairment. The lower quadrant exam should be the same for any condition from the lumbar spine/ribs to the toes. When performing a lower quadrant examination - have a routine and actually think about what each test is telling you.
- Go back to the anatomy text book and revise your knowledge about the anatomy of abs. This is something Physiotherapists are getting a bad reputation for because in general, they focus too heavily on transversus abdominus (TrA) and don't take enough time to consider the important role of external oblique, internal oblique and rectus abdominus. It is not all about TrA and was never meant to be.
- Think horses not zebras. This comes from the quote "when you hear hoof feet, think horses not zebras" which I have heard many times before in the context of clinical reasoning. Shirley emphasised that we might, as a medical society as a whole, be focussing on the complex less frequent conditions and overlooking the obvious answer. Weak abs aren't a pathology, short hamstrings are a pathology but if we put enough of these abnormal movement patterns, flexibility, and strength impairments together, they can create a primary structural pathology. An accumulate of poor motor patterns is enough to cause structural pathology and pain.
- The path of least resistance is not always correct. Relative flexibility, relative stiffness, and motor learning combine to contribute to the development of a path of least resistance for movement. But, more efficient doesn't mean more effective.
- The assessment and correction of how patients perform daily activities is critical in helping them manage their pain. This is why we can’t tell people to keep their spines in neutral all day long or tense their core in all ADLS. Daily life demands variability of movement. And if we don’t actually address these daily postures and movements, we may never truly identify the contributing factors to sustained movement system impairments. As Shirley put so eloquently “If it can change so readily within an assessment, why does it keep coming back with daily activity?”
- You get what you train. The secret to success is understanding what a motor learning paradigm look like i.e. teaching patients how to wash dishes, lift, bend, roll, tie up shoelaces, stand on one leg to put on pants, pack luggage and carry children. You can teach someone to bridge but will that teach them how to roll over in bed or how to transition from sit to stand? Isolated exercises don't integrate into functional movements unless they are taught. Purely strengthening a muscle doesn't teach you how to move well with it.
- If your hips don't move properly you'll injure your back and vice versa. There are so many muscular contributors of the hip that impact the back directly e.g. reduced hip rotation causes increased back rotation, Cam lesions result in increased lumbar flexion moments, and weak hip extensors create increased flexion loading of the spine. One really valuable aspect of this course was the lecture on structural variations of the hip and how they impact and relate to the lumbar spine.
- We need to spend more time carefully watching how people move. A key point emphasised by Shirley was that the pelvis should rotate 4 degrees around the central axis, therefore, if one can see it, it is moving too much! I really appreciated how carefully Shirley performed each active and passive test and the information she drew from both palpation and observation of the quality of movement.
SUMMARY
- You can’t begin to treat a lower back problem if you don’t consider the hip.
- Consider quality and quantity of range - taking into account ROM, where is is coming from and understanding how each abnormality relates to the overall pattern.
- In-session change in pain or symptoms is key!
- Your body is a reflection of how you use it.
- It is more important to find out why a muscle is short than to address it.
- The body takes the path of least resistance.
- You have to change the way you move with ADLs.
- If you can see lumbopelvic rotation during walking, it is too much.
Shirley emphasised that novice Physiotherapist’s often don’t have a consistent examination procedure which prevents them from developing pattern recognition. This consistency in routine was a huge teaching element of my masters degree. Initially I found it frustrating to go through such a long process every time but now I respect that if you don’t assess something, you can’t rule it in or out as part of the overall problem. Overtime pattern recognition is about being able to know what are common features of a condition but also what are not. Pattern recognition is what makes you an expert.
I want to thank Shirley for continue to share her knowledge and passion with Physical Therapists and for reminding me that the journey towards a greater understanding and deeper knowledge of the human body and movement never ends.
Sian Smale is an Australian-trained Musculoskeletal Physiotherapist. Sian completed her Bachelor of Physiotherapy through La Trobe University in 2009 and in 2013 was awarded a Masters in Musculoskeletal Physiotherapy through Melbourne University. Since graduating from her Masters program, Sian has been working in a Private Practice setting and writing a Physiotherapy Blog "Rayner & Smale". Prior to moving to San Francisco, Sian worked at Physical Spinal and Physiotherapy Clinic and has a strong background in manual therapy and management of spinal spine, headaches and sports injuries. Since moving to the Bay area, Sian has become a Physiotherapist for the Olympic Winter Institute of Australia, traveling with their Para Alpine teams. Sian currently works full time at TherapydiaSF as a physical therapist and clinical pilates instructor.
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REFERENCES:
Sahrmann, S. (2010). Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines-E-Book. Elsevier Health Sciences.
Sahrmann, S. (2002). Diagnosis and treatment of movement impairment syndromes. Elsevier Health Sciences.
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