Do you want to know more about Craig Liebenson and his functional approach? Last week we shared part 1 of this interview with an introduction of who he is and his functional movement approach. Read part 2 of this great interview and learn more about:
12/ You have selected 7 basic exercises for making a global assessment of the patient. You named them "Magnificent 7". Could you briefly list these tests and explain how they can identify abnormalities that you marked in the previous question?
The 7 tests are simple procedures which allow us to screen sagittal, frontal, and transverse plane motor control. We are designed to be upright. Over 200,000 years ago this function evolved in Homosapien. In just the last generation or 2 we have polluted this posture by overemphasizing sedentary postures such as sitting. After testing range of motion of the painful region for “markers’ of pain and orthopedic diagnosis we perform the 2nd test the Wall Angel. This along with the 3rd test the Overhead Squat screen upright posture function.
Our 4th and 5th tests are for the frontal plane. Humans are designed to move. We evolved to walk 20,000 steps/day. Today in western societies the average person walks under 7500 steps/day. In normal cadence gait about 85% of the gait cycle is spent in single leg stance. For this reason Pr Janda said we should re-define posture from 2 leg upright stance to single leg.
In our 4th test single leg balance we look for an inability to balance on each leg with eyes open for 10 seconds or with eyes closed for 5 seconds. Normative data exists for this important test which is a risk factor for injuries in soccer players as well as falls in the elderly. Our 5th test is the single leg squat which I have already described.
Our 6th test screens for transverse plane function. At 6 months we begin rolling movements and these rotational patterns become part of creeping, crawling, gait, and most sports or recreational activities. The single leg bridge is an excellent screen of stability of the lumbo-pelvic region in the transverse plane. Typically a dip will occur in the pelvis.
Our 7th and final screen maybe the most important of all. It is of respiration and intra-abdominal pressure (IAP). Dr Lewit said “breathing is the most common faulty movement pattern.” Chest breathing is typical and overloads the cervical spine as well as impairing abdominal function. If relaxed breathing occurs with vertical motion of the rib cage substituting for horizontal motion of the abdominal wall this is dysfunctional.
Finally, IAP is assessed as per Dr Pavel Kolar’ recommendation. The test evaluates our patient in the dying bug position or triple flexion position of a 4 month old baby. The key is to assess if our patient can depress their T/L junction against the table or floor independent of the phase of respiration. The anterior-inferior rib cage should be seen to move down. Even with inhalation we want to see this position be maintained.
13/ We would appreciate if you could give us 2 examples of tests and exercises to understand this approach.
Let’s say a person with knee pain has poor control of hip abduction and 1 leg squat. If we find that contralateral QL/oblique abdominal activation irradiates into the gluteus medius making it immediately stronger then we would recommend exercises such as bottoms up kettelebell carry and baby get up for the patient.
14/ In what respect is the Magnificent 7 different from Gray Cook’s “Functional Movement Screen”?
They are very similiar. In the Mag 7 we call the Overhead Squat a dysfunction though if end range lumbar flexion occurs before the thighs reach horizontal. We also assess single leg stance positions and respiration directly which we feel is essential since these are fundamental functions.
15/ The first test you perform with the "Magnificent 7" approach is the one of lumbar mobility in search of a stiff or hypermobile area that you objectify with inclinometers. What is the purpose of this assessment?
This test is variable. We look at range of motion of whichever area is the patients chief complaint. It is basically an orthopedic assessment.
16/ Doesn’t this test contradict with McGill’s approach that considers that "no matter how the back moves, what is core is that it is maintained" (locking the lumbars in addition to a good hip mobility being the key)?
Not at all since we are merely testing for mechanical sensitivity. This is not training. Pr McGill also tests for load tolerance. These are not training positions.
17/ In this first test, how will you use the information that the patient is hyper or hypomobile?
If a patient is hypermobile we are particularly concerned with ergnomic strain during sitting.
18/ How do you score your tests and what should the overall score be at the end of the tests?
Like w/ the FMS the scoring is 0-3 for a maximum total of 21. The goal as with the FMS is 7 symmetric 2’s. Our goal is at least a 14. The goal is NOT to have a 21. We want to convert 0’s & 1’s into 2’s. Not 2’s into 3’s. Dr Lewit famously said, «don’t try to teach perfect movement patterns, correct the key fault that is causing the trouble. »
19/ What goals do you give to your patients?
Most goals come from the patient. I believe in patient-centered not doctor-centered care.
20/ How do you work? Do you recommend exercises or do you practice consistently the exercises with your patient?
I evaluate each patient on every visit. We want to know are they feeling improvement, the same or worse. Then we review their activity intolernaces. Then, we re-examine their “marker” tests (0’s) and painless dysfunctions (1’s). Finally, we review their self-care. If they are improving we have to increase the challenge of their exercises. If they are not feeling better we have to see if we are addressing the wrong painless dysfunction.
21/ Does the quantitative evaluation (strength, endurance) of muscle groups have room in your approach?
Yes, we quantify capacity measures such as side plank endurance, 1 leg balance time, Range of motion, etc. But ,more important is to qualify competency measures such as faulty movement patterns.
22/ What is remarkable in your book is the integrated approach where, for example, a patient consults you for a common low back pain. Your clinical approach consists in trying to identify the cause of the pain first (for example: is it discogenic or does it come from a facet?). What importance do you give to this diagnosis, and how do you link it with your functional analysis?
The diagnosis is Step One. Rule out « red flags » of sinister disease processes. Then, determine if there is a specific structural pathology (i.e. herniated disc pinching a nerve). But, in 85% of cases it is not posssible to give a specific diagnosis with certainty. This is where the functional approach shines. We focus in a patient-centered way on their activity intolerances related to pain. The Assessment-Correction –Reassessment process I call the Clinial Audit Process (CAP) is the key to identifying reversible functional pathologies of the motor system.
23/ In the cases mentioned, what do you do during the acute phase of treatment (discogenic pain versus facet pain) ?
Disc we follow McGill’s spine sparing strategies (hip hinge, avoidance of flexion) often w/ McKenzie protocols if centralization can be achieved. Facet often responds to adjustments plus exercise.
24/ When the acute phase has passed, what happens to your care and what are, in general, the clinical features and exercises that you see in these two types of injury?
As the acute phase subsides there is less need for an anti-inflammatory approach and gradually exercises progress from establishing a foundation in competency to one which begins to build capacity.
25/ At this time of evidence-based medicine, what can be said about this functional approach? Is there, for example, evidence of the reproducibility and validity of the tests that you present?
Most of the tests are evidence-based (i.e. single leg balance, single leg squat). However as Dr Lewit said, « we work at the level of acceptable uncertainty ». The functional approach is highly evidence-based, but there is a still a lot to learn. There is a danger w/ evidence-based methods in that if we assume our patients make up a homogenous popultation when in fact they are heterogenous (C LeBeouf) we will miss out on specific management strategies that work in subgroups.
26/ What is the average number of sesions needed to rehab a patient ?
There are some people who never reach a 2 on all tests. The Mag 7 like any functional screen is a starting point. Since every exercise is a test we are learning all the time. The goal of assessment is as Dr Lewit said "to find the key fault that is causing the trouble." In the functional approach this can be a moving target. As we build fundamental movement competency then we move on to building more capacity. All the while the emphasis is on what activities the patient performs so the target is different for everyone and the Mag 7 is really just a jumping off point.
What I can say is that progress should begin immediately with nearly all patients. By that what I mean is that mechanical sensitivity of "markers" of pain should be decreasing with each and every visit. This occurs as a result of enhancing movement competency of "key links" that have painless dysfunctions or abnormal motor control.
27/ From the therapeutic standpoint are there clinical trials demonstrating the effectiveness of this approach?
Yes, please review the works of Frost, Fritz, Hubbard, et al. Most of these are summarized in my book.
28/ What are the future prospects in terms of research?
We need more. They are very bright. Pr McGill’s lab for instance has been studying in active individuals how the activities one participates in has more to do with injury risk than fitness does.
29/ As this interview reaches its end, do you have anything to add?
It was a great opportunity for me to come to Paris and teach at the Institut Franco-European de Chiropratique. We had a wonderful atmosphere as the snowfell on Paris. I could see how excellent the training in manual skills is in France. My hope is that our observation skills and our ability to not only treat, but also teach and train our patients will evolve in the coming years. I hope to see many people join the International Society of Clinical Rehabilitation Specialists www.clinicalrehabspecialists.org and for both French campuses of IFEC start Rehab 2 Performance (R2P) clubs to help students learn how to “bridge the gap” from manual skills to rehab.
Thank you very much for your insightful questions.
Source: 17/04/2013 -
http://vertebre.com/craig-liebenson-dc-308
Interview of Craig Liebenson, DC
Interview conducted by Karl Vincent DC,
President of the Franco-European Chiropractic society (SO.F.E.C)
Member of the Board of Governors of the Franco-European Chiropractic Institute, http://www.ifec.net/
With the participation of Cyril Fischhoff, DC,
Member of the Board of Governors of the Franco-European Chiropractic Institute, http://www.ifec.net/
