I recently had a newly graduated physical therapist, with their new car smell, ask me my opinion on the best standardized assessment tool or system to treat with. Do I prefer MDT, SFMA, Dry needling, PRI, or add your alphabet soup here. Or another way of asking, when do I implement a certain system and not the other one?
My first response:
“Go find purple flower in mountain and then I share wisdom with you”
My Second response: It depends (this is an obvious answer for most “eclectic” PTs) Ok, but what does it depend on? It depends on the musculoskeletal error; either positional (error 1) or kinematic (error 2). Let’s remember the function of skeletal muscle:
- It maintains or influences posture. Again, we'll call this positional
- It produces force and locomotion. For reinteration, we’ll call this kinematic
Therefore, with a wide brush here, skeletal muscle can only have two deficits or errors (or a combination of both). It can be dysfunctional with the position of a joint and the corresponding muscles attached. Further, this can be dysfunctional with this position at rest or at end range(s). Or, it can be dysfunctional with how you move (quality or quantity).
Another way I think about it is my golfer analogy: you can either be a great golfer with a perfect swing but you set up on the tee box pointing away from the flag and the wrong direction (error 1). It doesn’t matter how great you are if you start in the wrong position. Or you can have a bad swing that compromises the direction the ball goes (error 2).
So depending on the error and how you breakdown the respective error will be your best assessment tool. Here’s my algorithm:
musculoskeletal dysfunction (non-acute/traumatic):
1. positional/postural deficit--> therefore change the position/ PICR--> what's best for this would be MDT. We need to centralize, or reposition, with repeated end range motions. MDT has a ton of research to show how they fix the positional fault. For sake of brevity, I won't go into it today. Whether we are centralizing nucleus pulposus or the humerus on the glenoid we improve the position.
A. static or midranges positional (derangement). Therefore, use opposite direction to
“realign”. Progress load as appropriate.
B. end range positional (derangement and dysfunction)
C. sustained positional (postural). Therefore use postural education to realign.
D. structural deficit (frozen shoulder, flat feet) / alignment (scoliosis). therefore orthotics, etc and education.
2. kinematic/ movement deficit--> Therefore change the movement strategy (quality or quantity) or muscle tissue quality (ie the ATrP). I use SFMA here to assess movement deficits which differentiate b/w:
A. motor control (more likely than true mobility)
- This can include firing latency, muscle activation, improper henneman’s/high threshold deficits, Crossed Syndromes, etc.
- First, has the muscle gone into a protective response leading to ATrP? Yes: we need to stop and treat this chemical pain first, otherwise were building motor control on a faulty engine. Therefore TDN (or whatever you do for TrPs and/or to get a mechanical and neurophysical reset) and Correctives to reintegrate (PNF) the new end range of the specific pattern.
- Poor motor control without significant ATrP.
- Motor control without CE being the main influence. Then use Sharmann or Gray Cook or PNF philosophies to reset, reintegrate and reload. Again, this can be a lengthy discussion but my short answer is there are several corrective exercises designed for almost any specific movement to reset the tissue and the respective muscle pattern.
- mvmt competency only: therefore need only motor learning/feedback. Some people just don't know the movement because they don't do the movement.
B mobility. therefore loss of motion in passive, unloaded positions.
- joint/capsule- therefore I may SMT, MWM, Repeated end ranges. all are shown to be equally effective.
- tissue- TDN (especially with ATrP and LTrP) , IASTM, Contract-Relax
- tone- foam roll (DNIC) and stretch (CR,AIS)
- contracture: stretch and dynamic stretching brace
As I learn more I’m sure this will continue to change/evolve along with doing my best at following the evidence. Hopefully, this may help you reconsider your ‘why’ that you use a certain assessment tool and the importance of understanding multiple assessments.
What else do you fit into this algorithm? Do you have a better one? let me know!