The SFMA uses a 4×4 Matrix when prescribing exercises. It is a useful guide to follow when trying to decide on the challenge level that is appropriate for your client.

The TUG. Moving from the ground up.

There are 4 positions:
1. Prone / supine
2. Quadriped
3. Half kneeling and tall kneeling
4. Standing: squat, lunge, step up (single stance)

The progressions come from the neurodevelopment theories of gait progression.

There are four loading levels are:

1. assisted / unloaded  (Reactive Neuromuscular Training (RNT))

2. unloaded (no load)

3. assisted / loaded (RNT + resistance)

4. loaded (resistance)

You always start clients on the ground. Once they have mastered the ground exercises they can progress to the quadriped positions and so forth.  It is important to challenge your clients but even more important for them to be able to complete the pattern without compensation. If a compensatory pattern is evident (poor posture, breathing, unstable) the challenge is too great and the client should do the exercise at a lower level.

I had a  client with recurring ankle sprains. His SFMA scored card read:

CN: FN

Sh: FN

MS Ex: FN

MS flx: DN

MS Rot: FN

SL: DP (unstable and pinching pain)

Squat: DP (pinching pain)

His MS flexion revealed a combined tissue extensibilty and motor control issue. I started by treating the painful ankle with a  grade 3/4 PA glide. Retested the squat: less pain. Retreated and then followed up with a motor control exercise for the ankle. I always try to follow up mobility gains with pain free exercise that will work to solidify the gains made.  We followed the 4×4 matrix and started at a 1×1.  After a few sets, we retested the squat and single leg stance: both improved. I then moved to the hamstrings. I did  a PNF pattern to lengthen the hamstrings. Re-tested MS flx: improved but not fully. Next we tackled the lack of motor control during MS flx. I had the client do a 1×2 and 4×1 exercise. Did 2×15 of each exercise and then re-tested: MS flex: still DN but closer.  I sent the client home with

1. rolling supine to prone and prone supine (lower body) (1×2)

2. SL raise with core contraction (1×1)

3. ankle self mobilizations

4. ankle exercise using a swissball and theraband (1×1)

I saw him 2 more times over the next 2 weeks. He has since been discharged and is playing soccer regularly.  Not every client is going to work this nicely but he was a great example of how mobility and motor control, work hand in hand and how you can use the 4×4 matrix to guide your exercise selection.