Functional Movement: An Interview With Gray Cook (Part 2)
By Robert "Skip" George, DC, CCSP, CSCS
Part 1 of this article appeared in the April 2013 issue.
Gray, there seems to be a revolution right now in “physical medicine" toward a potpourri of treatment applications and practitioners, like personal trainers, who perhaps aren't diagnosing back pain, but are certainly treating back pain and other physical ailments. The Information Age is upon us and many different practitioners from many disciplines are treating these ailments. Can you speak to that? First, treatment without diagnosis is irresponsible, in my opinion. It's almost like going to a pharmacist and asking for a medication. That pharmacist does not have the clinical ability to diagnose you, but right behind them they can dispense a “potpourri" of things to make you feel different.
Now don't get me wrong; I truly appreciate, for example, what a massage therapist can do. I think they have skilled hands and can get in there and work the tissue like no one else. But you and I have been trained to find the driver of bad movement, to find the source of the pain. Sometimes rubbing on the sight of discomfort distracts you from making an appropriate diagnosis.
We have innovative, aggressive ways to treat soft tissue. Dry needling and ART (active release technique) are on the forefront of aggressively treating soft tissue so you don't have to go to a massage therapist for a year to get rid of unnecessary tightness, for instance, in the “traps." Just because someone may have had previous success getting people in shape, or whatever, does not mean the treatment justifies the lack of a diagnosis. I can give you morphine right now and you will feel significantly better, but it does not mean that I have diagnosed you – or that you have a lack of morphine in your system! (Author's note: Chiropractors have said the exact same thing since day one!)
If I had to dedicate myself to being an expert in diagnostic abilities or treatment abilities, and could only pick one, I would choose to be an expert in diagnostic abilities. This is because I would soon figure out and how to change the baseline. If all I had was treatment, then I would try to force every patient into my treatment zone. So, if you are good at diagnostics, one of the first things you will figure out is that you may not have the skill set to fix the person if front of you; but I am a phone call away from being able to network, and I have never found a patient yet or a referral source who didn't appreciate a well-diagnosed, well-managed referral. In fact, it usually comes back to me tenfold. I do think that diagnosis is a lost art, and movement screening and movement assessment are sort of my contributions to get us back to that critical thinking.
So, talk to me then about the use of the Functional Movement Screen with organizations, professional sports teams and some of the people with whom you have personally worked. I'm very honored that the FMS has made it into the special populations of the military, the NFL and many other professional sports. And I think there is a certain “dogma" that surrounds the movement screen. It is either the savior of everything or it is the worst thing that has ever happened! In truth, it is neither. It is simply a tool that did not previously exist in our toolbox.
Once you introduce a new tool, it doesn't mean you lose all of the other effective tools. It sits right beside the other tools. And I'm not saying that there aren't some tests we should probably delete [from our toolbox]. As a matter of fact, there are a lot of innovative orthopedic books out that say some of those tests we used to do are either unreliable or not valid. So, if we were to delete at least those – not based on my opinion, but current evidence – then we would have plenty of space to add a new tool or “app" to what we do.
It seems to me that is the revolution Craig Liebenson, DC, spoke about in a course he was teaching a few years ago, when he said that everything in rehab and the functional approach to patient care changes every five years. Could you talk about that and where you see all of this going – the FMS and all of the new approaches in health, fitness and movement? Well, the first thing I see is that as soon as the FMS gets a little more popular than it already is, you will see a lot of “movement screens" come out. You will see a lot of copycats. You see exercise videos, exercise equipment and protocols get copied. So, I would say we will see some new screens come out.
And I would at least throw down the sword out front and say listen, if you are going to beat the FMS, then beat it. But copying it ain't gonna beat it. I see people doing that; they take the movement screen and delete two tests, add one and then brand it as something else. I think that is closer to seeking popularity instead of really trying to change the baseline. I am absolutely sure that we will have a better way to screen movement one day. Until we had a GPS, we had to be good at using a compass. That GPS isn't available now [for movement screening], so until it is, let's use the compass and wear it out so as not to get lost!
Like I said, a lot of copycats are going to come around just because screening is popular. And what will happen is that the pendulum will swing. First of all, people will take the simple screening concept we have offered to the exercise profession and do exactly what you talked about in terms of getting into assessment and diagnosis. That is the pendulum swinging too far; taking irresponsible liberties with a skill set that is not designed to be clinical. Second, we could swing the other way and say we shouldn't do any screening at all, and that all we should be doing is counting “reps." I think that is irresponsible as well.
As time goes on and the FMS gets more popular, it also may polarize people, with some saying it is too invasive or not thorough enough. The movement screen is here to categorize people in terms of both function and dysfunction. And if we can at least agree that we shouldn't lump a bunch of fitness on top of dysfunction, then [the FMS] has done its job.
You have worked very well with other professions, especially the chiropractic profession. Despite our respective professions' competition with each other, you even have chiropractors as FMS instructors, correct? I think it is a breath of fresh air because the one thing I think about chiropractors, and I am going to speak specifically about the chiropractors who help us, is that they seem to be significantly more “fitness savvy" than physical therapists who work with us. Unless a PT has a previous athletic background or sports medicine background, they don't really feel comfortable in a fitness environment.
I think it is because PTs don't go into independent practice. They work under the umbrella of a hospital or large clinic; whereas chiropractors come out of school and realize, “I've got to be a community resource right away. I‘ve got to distinguish myself right away. If I give all Pilates and yoga instructors a discount for care so I can educate them about the service I might provide to their clients, or if I work with the local triathlon club or personal trainers, and maybe even offer them continuing education twice a year, then I am going to become a resource in my community who appreciates fitness and wants to keep the active population moving."
It's a good business model. Active people are going to get hurt more by the simple fact that they do more. You can position yourself to be there and make that injury a temporary inconvenience, instead of a long-term issue requiring medication. The chiropractors we have [utilized] have not just been competent clinicians; they have become role models for how you manage a clinic and fitness side by side.
What value would the FMS bring to a chiropractic practice today? Here's just one example.I mentioned about being a community resource. Often the sports medicine specialist or the orthopedist shows up on sports physical day at the local high school and they are looking for medical contraindications to participation in sports. If the chiropractor teamed up with the school's athletic trainer and did movement screening, it would not interfere with the pre-participation physical conducted by the medical physician. The chiropractic physician, the PT and the athletic trainer could collaborate on the screen.
In your lectures, you talk about how we all have been told to "see your doctor before starting an exercise program." You follow this with how many people are told to “see your movement specialist before starting exercise" and who better than chiropractors and physical therapists to assess and be the “go-to" professionals for movement? I recently spoke at the International Federation of Orthopedic Manipulative Physical Therapists meeting in Quebec and said, isn't it ironic that dentists look into your mouth for prevention once or twice a year? They have demonstrated that they can avoid costly care with an ounce of prevention.
Wouldn't you like it if chiropractors could do a yearly musculoskeletal checkup? We [PTs] would love that, especially if insurance gave us about a hundred bucks to do it! I'd crank them out about every 20 minutes! And more importantly, I would uncover some stuff that I would go into clinic to treat.
Every dentist has a standardized, accepted checklist. Here is the disappointing thing: We [chiropractors, physical therapists] are a long ways from getting that wellness checkup because everyone does something different. We need to standardize that procedure.
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