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You Need a System

Systems help us with clinical decision making. They guide our treatments and give us a framework to lead our examinations.

I graduated from PT school knowing I had to do OMPT. I almost because a chiro, but my current business partner, then manager of the hospital rehab dept I was doing my final internship at told me about Paris and the University of St. Augustine.

Like many other OMPT approaches, I was bombarded with PIVM in every possible plane and position, as well as literally hundreds of manipulative techniques. That was daunting for a new grad, but I managed to get certified after taking all the courses in 1 year. Ironically, I got a questionable pass on extremities manual techniques and of all things soft tissue! Three months later, I flew back down to St. Augustine, got tested for 1.5 hours, then flew back, having passed. That's what you get for trying to pass a demanding certification by one of the founders of the AAOMPT with only 1 year under your belt. Quick moral, and what we preach in fellowship: everyone passes if they try hard enough, possibly just not the first time!

Back to the story; while this gave me a lot of tools, it did not give me a system other than look for restrictions and start with soft tissue techniques, then mob or manip those joints! This works for many patients, and it was mentioned that obviously, we should look at adjacent joints. This gets you to chasing pain in cases that do not respond, or respond, but then do not improve.

I next got credentialed in MDT, which I did for the heck of it, but not until years later, would I become such a staunch proponent of the system. Regular readers know I do not use it exclusively, but find the repeated motion exam simple, reliable, and a good prognosticator of future outcomes. It helps to know whether or not a patient will respond rapidly or not. It also helps you give a very simple and effective HEP.

At the time, I laughed at the few techniques they had, but now appreciate the simplicity of the system. You listen to the patient, see which movements worsen and improve their symptoms, and base their treatments on the directional preference. Simple... you can leave the first course knowing exactly what to do and most likely help patients on Monday morning.

The SFMA does the same for assessment of regional interdependence. It is a systematic look, derived from Cyriax and others, at movement of the entire body. It tells you whether something needs manual treatment or a corrective exercise strategy. It also leads you to treatment (assuming you have the tools to correct the dysfunction you find).

Does everyone need to go through the entire SFMA? I'd say that depends on your population, it is certainly more relevant than the FMS is for sedentary people. I may do the entire SFMA over 2 visits, or just use the upper and lower body breakouts for a office worker with a headache or knee pain - except thoracic in both. Your mileage may vary, but that is my current system. This changes at least yearly depending on my experiences in what works and what does not.

In summary, these systems give you a step by step method of looking at movement and positions. When I teach my students to examine patients this way. They often say, "it's so simple!" Yes, it is. You often do not need a myriad of useless special tests, especially in the absence of trauma. Your system may not match mine, but just make sure you are left with something to do after you're done examining your patient. Hopefully, it won't be ES and US.

This is the Clinical Decision Making Tree I use during examinations

  1. history
  2. observations
    1. structural
    2. emotional (catastrophizing, coping, etc)
  3. AROM
  4. repeated motions
    1. this is first because you can take a patient in excruciating pain and get them to rapidly improve
  5. SFMA
    1. often broken down to upper and lower breakouts depending on athlete vs sedentary
    2. this replaces my previous PROM testing as it includes it
  6. soft tissue assessment
  7. neurodynamics
  8. neuro exam if necessary
It is rare these days after an exam that I tell a patient I have no idea what is wrong. However, in the event that occurs, as long as I follow my system. I will have something to get my hands on, make it move properly, and correct the movements with exercise after. Correcting movement and reducing pain through efficient movement is often more powerful than giving a "diagnosis" based on ruling in an out conditions with special testing.

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