Top 5 Fridays! 5 Differences Between Multisegmental Extension and Extension in Standing | Modern Manual Therapy Blog

Top 5 Fridays! 5 Differences Between Multisegmental Extension and Extension in Standing

Dr. Charlie Weingroff recently got some heat for trying to give his spin on the SFMA and MDT and what happened in a Dr. Craig Liebenson video assessment. Here are 5 differences between the SFMA's Multisegmental Extension and MDT's Extension in Standing.

In the left corner, we have the original system traditional OMPT systems love to hate, MDT! In the right corner, we have the SFMA, a system of assessment that the sports med world loves and most of the ortho world has never heard of! FIGHT!

Ok, more like compare and contrast, just like we used to in grade school!

1) REIS is a movement and a treatment

  • prior to checking you get a baseline of symptom intensity (if any) and location
  • it checks the amount of repeated extension - look for deviations 
  • it checks to the effect of repeated loading into extension and end range affects the patient
    • pain during movement - typically derangement or rapid responders
    • end range pain - could be derangement, or if loss of motion dysfunction or slow responders
    • the repeated loading effects could be changes in
      • pain 
        • intensity
        • location - centralization, peripheralization
      • ROM - could increase or decrease rapidly
      • strength
      • DTRs or other neuro signs
      • function - the best functional test after mechanical loading for the lumbar spine is walking to see if the improvements are stable
  • the movement is a gross osteokinematic movement but targeted at the lumbar spine, the goal being to get to end range 
    • getting to end range means as little as possible movement in the other adjacent regions in contrast to MSE
2) MSE is a movement assessment
  • the movement is a true (functional) or false (dysfunctional)
  • functional
    • arms overhead
      • tests shoulders and thoracic extension
    • segmental motion
    • scapula goes behind the heels
      • indicating good segmental extension
    • ASIS goes anterior to the feet
      • testing hip extension, ankle dorsiflexion
  • dysfunctional = missing any of the above components
  • it either hurts or it doesn't = painful or non-painful
3) REIS may lead you to a specific directional preference of treatment
  • if extension in standing reduces the patient's complaints, improves ROM or any other objective change, the DP is extension
  • this leads you down the path of the extension principle or choosing treatments based on loading and unloading into extension
  • you instantly have an entire treatment progression lined up along with cause and effect, education, and emphasis on patient responsibility toward self treatment
4) MSE and the breakouts lead you to dysfunction and asymmetries
  • in checking MSE, you may find it is dysfunctional because of left ankle dorsiflexion, right hip extension, thoracic extension, and left shoulder elevation (all examples)
    • these lead you toward your treatment of choice to restore mobility in those areas, targeting the most distal, dysfunctional non-painful areas first
    • this is a check that you will also not flare up the patient's condition with either OMPT or corrective exercises 
  • you may also find that if dysfunction in WB is functional in NWB - indicating motor control or stability issues
    • after assessing rolling patterns you may find that it is a stability/motor control issue, which then needs corrective exercises
  • the main difference is that the SFMA is an assessment that tells you where and what to treat, what you choose for treatment is up to you
  • hence, it is not a method, ala MDT, but a systematic approach to looking at regional interdependence
5) REIS (MDT in general), much like the honey badger DON'T CARE about motor control, stability or strength
  • McKenzie would often quote Cyriax who stated, "Why should you strengthen a man's back? He will only hurt himself more by lifting more than he is able to!" (paraphrasing)
  • yes, die hard MDT practitioners only look at movement and how it affects the symptoms and function of the patient
  • if you have an excellent MDT clinician in action, they really can make 80% of lumbar cases better without any hands on treatment, stabilization, or assessment of anything other than a few movements of one area
  • you could argue that not treating any adjacent dysfunction will only lead to patient's re-injury, but that would have to be studied as it is not proven yet
    • despite the lack of evidence, I think it is irresponsible not to work on adjacent dysfunction and the patient will most likely either be back for more care with a re-injury. That may be at your office or another provider since you didn't get the job done in the first place!
Hopefully those of you trained in one system and not the other glean some info from this post. Any other questions on the SFMA and MDT? Post them below or email me for future Q&A posts! Have a great weekend everyone! I'll be preparing for my first international course next weekend in London.......... Ontario!


  1. Great info E. I am not trained in either of these principles per say but use this assessment more indirectly and informally in day to day practice. Honestly, if you are a keen clinician, you can pick out the data you need with a naked eye and clinical reasoning. If you want to be called this certification or that, that is fine but I hope our profession doesn't get limited too much by practicing under one guru's thought process. In the long run, it will set us back.

  2. I didn't mean to have a negative connotation here, just hope we don't fight over certain approaches and further divide our profession at a time where we need to come together to obtain autonomy, define who we are and what we do.

  3. No negative connotation, I like certifications because I think preaching and knowing the approach I use is how it was intended. I also like hearing and learning from the horse's mouth.

  4. Yeh I agree with hearing from the horse's mouth. Next 5 yr plan is to do more of this.

  5. this was really a great informative post sir. I believe we can use both. We can target what's really bothering someone through MDT, while doing corrective movements to fix the dysfunctional segments we've seen thru SFMA, so clients won't keep coming back after treatment was done.
    well, I just can't believe as why Cyriax say that.. strengthening back muscle nowadays, not just really on heavy lifting isn't it?
    Sir, always have a great weekend and Godbless on your international course. :)

  6. We can absolutely do both, and yes strengthening someone's back is not about muscles, but more about quality movement most of the time. He was probably talking about crunches and supermans giving someone the false sense they can do more then should be able to safely and efficiently.

  7. "despite the lack of evidence, I think it is irresponsible to work on adjacent dysfunction". Did you mean to say "it is irresponsible to NOT work on adjacent dysfunction" rather than "work on adjacent dysfunction"?. I agree with the former, not the latter. Great post! That line was just a bit confusing to me, just wanted to clarify.

  8. That's definitely what I meant! You're the first person to catch that! I absolutely work on adjacent dysfunction! I'll fix it right away!