Dr. Shirley Sahrmann, OG of the PT World: A Course Review
Time for another course review! I recently took Dr. Shirley Sahrmann’s course entitled Movement System Impairment Syndromes of the Lumbar Spine, Hip and Shoulder. I was really excited to see Dr. Sahrmann speak in person as she is a true OG of the PT world, and there’s probably not a single PT school curriculum in the country that doesn’t cite her work in some degree.
A quick but hardly complete rundown of her educational, clinical and research career:
Graduated from Washington University with a bachelor’s degree in physical therapy in 1958!!
PhD in Neurobiology
Faculty at Washington University for 56 years
Maintained an active clinical practice throughout the past several decades until her recent retirement in 2012.
I was eager to learn from someone who has been in the game for almost twice as long as I’ve been alive. Imagine being at the frontlines of your profession for half a century, not only pioneering research but being able to witness that research being implemented into the field and applied into practice.
On to the nitty gritty. Although the title of the course Movement System Impairment Syndromes (MSIS) sounds a little complicated at first, Sahrmann’s reasoning for this name makes a lot of sense. When it comes to evaluating and treating pain & dysfunction, being able to diagnose what is wrong is important. Patients may feel more comfortable knowing there’s an actual name for the phenomenon that’s causing their pain (when you understand something, you feel a little more empowered over it). An important function of a diagnosis is to inform what is wrong and what requires intervention so that healthcare providers may act accordingly.
In physical therapy, the problem with pathoanatomic diagnostic categories is that it they’re inadequate in accomplishing this. Physical therapists are commonly taught that we are to “treat the person, not the diagnosis.” Our diagnostic nomenclature system as it exists now doesn’t really provide any pertinent clinical information to the physical therapist as far as treatment goes. This is true for almost all diagnoses--patellofemoral pain syndrome, biceps tendinitis, knee osteoarthritis, etc. Other than indicating the location in which the patient experiences pain, these diagnoses don’t really inform the clinician on how to specifically go about rehabilitation. Most importantly, they don’t tell you anything at all about what movement strategies the patient is using, which is one of the most important things we affect as physical therapists.
“Our diagnostic nomenclature system as it exists now doesn’t provide any pertinent clinical information to the physical therapist as far as treatment goes...[they] don’t really inform the clinician on how to specifically go about rehabilitation [nor] anything at all about what movement strategies the patient is using, which is one of the most important things we affect as physical therapists.”
The most prominent examples of this are low back pain disorders. For example: Intervertebral disc herniation, spinal stenosis, facet joint arthrosis, nerve root impingement, annular fiber tear, pars interarticularis defect, etc. Don’t get me wrong, it’s still helpful in some ways to know the physiological differences between these diagnoses, and certain precautions associated with them are not to be ignored. But how can we name medical diagnoses based on events that also occur in completely asymptomatic individuals? Research has shown that there are many people who present with these aforementioned things on x-rays & MRIs but are completely pain-free. Why should we name pathology after these things then, if they could just be normal age-related changes to the spine that occur over one’s lifetime?
What’s the standard physical therapy protocol to treat an L5/S1 posterolateral disc herniation? There is none because there’s not enough reliability in this diagnosis name to indicate consistency between patients who present with this.
Enter Sahrmann’s MSIS system. If our job is to figure out what movement strategies are causing the patient to experience pain, an effective diagnosis system should help to inform that. When evaluating a patient, if we can identify certain patterns of potentially dysfunctional movement then we can have more uniformity across our profession on how to go about treating them.
MSIS’s:
Are named for the impaired movement direction that reproduces symptoms. Restoring this impaired movement diminishes symptoms.
Identify the cause of the dysfunction and contributing factors
Provide a direction for treatment, and don’t require identification of a specific pathoanatomical structure as a source of pain
Still require knowledge & application of anatomy and kinesiology.
Key Principles
When it comes to movement, your body will take the path of least resistance that’s required. This pathway is influenced by the amount of available joint accessory motion (arthrokinematics like intrajoint gliding, rolling and spinning), relative flexibility between different neighboring joints (like the lumbar spine and hips), passive tension of muscle & connective tissue and your choice of a particular motor strategy.
In light of this, the way you do your everyday activities is of critical importance. Your job may require you to sit for long periods of time, and specific joints are constantly held in sustained positions for dozens of hours a week. Or maybe you participate in a recreational sport that requires repeated movements using heavy loads. Maybe it’s advantageous for you in that sport to move those loads at high speeds. And maybe you enjoy this sport so much that you do it 3 to 4 times a week every month. Over time, if your body is unprepared in terms of strength and severely lacking in terms of diverse or efficient movement strategies, a component of the minimally resisted pathway(s) your body ends up using may get overloaded and lead to pain.
Intervention of MSIS’s involve the following:
Identify the movement system impairment. What is the motion that the patient dislikes doing? What position is it that they can’t get into?
Identify the contributing factors. Is a body part not moving enough? Is one moving too much?
Educate the patient about what his/her body can’t do. In order to get better, the patient needs to eventually reacquire that lost motion through corrective exercises. Identify what motions may need a temporary rest so as not to exacerbate the contributing factors.
Final Thoughts
The core of Sahrmann’s approach makes sense to me. I can understand how her system has stood the test of time and is taught in so many schools around the country. There is a heavy emphasis on performing a detailed examination of all regions that may be involved with the pain. She moves away from the need to identify a target tissue or structure as the source of pain, and rather looks at what movement is lacking (or excessive) that is causing the pain. She still encourages heavy reliance on knowledge of anatomy, physiology and kinesiology to perform physical examinations.
This may be a nitpicky detail but I think it’s more accurate to say that our bodies will lean towards taking several different paths of less resistance as opposed to always taking the past of least resistance, and that this depends highly on the task at hand and cognitive motor strategy employed. If this is the case, then that means there’s more than one solution to successfully rehabbing a movement syndrome and it would behoove us to diversify our available movement repertoires with as many options as possible. The more tributaries that flow from the main river, the less chance there is to overflow any single one and thus avoid pain.
I think the sequence in which one conducts different components of a movement evaluation is vital. In the SFMA, if someone performed a top tier movement that you assessed to be dysfunctional, before you could draw any conclusions about what joint was contributing to that (and how), you had to follow a specific evaluation algorithm to rule out or rule in certain causes. I'm not sure if sequencing is as vital in Sahrmann's approach, so long as you are thorough and look at everything.
Also, unless I am interpreting her incorrectly, I also disagree with Sahrmann’s concept of there being optimal movement. In certain examples she gave, she seemed to suggest that moving “precisely” would help stave off the mechanisms of injury described above. But this can be countered by observing people who constantly move with “non-optimal” alignment or postures and yet remain completely pain-free. It’s why it’s so hard to actually predict injury in patient populations.
Perhaps one of the things with which I was most impressed by Dr. Sahrmann was her vocal advocacy for the modern day physical therapist as being on the front lines in the war against chronic, degenerative musculoskeletal conditions. I totally identified with this in my role as a PT. We’re in positions to evaluate how people literally move their bodies and therefore how they go about performing every physical activity. We have the ability to prevent things like osteoarthritis by identifying patterns and intervening before the microtraumatic stressors lead to macrotraumatic injury. I really think the role of PTs have evolved in the 8 years that I've been in the profession, and this is how I feel the role will continue to evolve and positively affect the most people with our clinical skillset.
Earlier in this post I mentioned how Sahrmann has been in the field of PT since the 50’s, but that she still very much has her head in the game on so many levels. Throughout the course she continually recognized that physical therapists today are like musculoskeletal dentists. People should make regularly scheduled check-ups to physical therapists for movement evaluations to screen for potential problems down the road. Preventative healthcare is the best kind of healthcare because they stop problems before they become problems. In my opinion, I already think this is beginning to happen in our field (or at least with athletic populations) as physical therapists are becoming more popular as clinicians who have to ability to diagnose movement to enhance athletic performance. Gone are the days where PTs are solely body workers, providing passive modalities like massage, hot packs and electrical stimulation while prescribing generic exercise based on unsupported pathoanatomic narratives. We’re the new healthcare wave of tomorrow, proclaimed by Dr. Shirley Sahrmann herself who has seen enough of our profession’s past history to help predict its future.
Me with a legend!
This review is my personal interpretation of Dr. Shirley Sahrmann’s principles and was written based on my understanding of her two-day course. In order to most accurately learn about Movement System Impairment Syndromes, you can read her books Diagnosis and Treatment of Movement Impairment Syndromes and Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines.
**11/24/18 addendum: It was later revealed to me from a fellow faculty member of Shirley’s at Washington University that “movement precision” referred to when appropriate arthrokinematics and sufficient strength/control was present in a joint to enable it to move healthily, as opposed to a goal for a gross movement to move in a specific/particular way.