Using two different statistical techniques, the authors performed a factor analysis to determine if the individual tests of the Functional Movement Screen are independent of each other or sum together into one construct. Basically, they looked at whether the total score of the FMS is useful to reveal the whole picture of an individual’s movement or if the individual score on each test needs to be considered.

The sum of the parts is not necessarily the whole

Here is what they found:

 “Results do not offer support for validity of the FMS sum score as a unidimensional construct.” 

 The individual test results give different information than the total FMS score. In other words, a score of 1 on the push up is not measuring the same movement construct as a score of 1 on the squat.

Another quote from the study:

“When using FMS results to communicate with patients and to direct rehabilitative needs, the sports medicine professional should focus more on the individual movement scores rather than the composite score”

This is definitely the case, as a person can have a composite score of 16 and score a 1,3 on the Active Straight Leg Raise and a zero on the squat. Even though the person has a high composite score, he still has pain and substantial fundamental movement deficits that must be addressed.

Bottom Line: While the Functional Movement Screen composite score was initially used in injury prediction research, the score on the individual tests is more important. In my opinion (supported by the research), you should not have any 0’s (pain) or 1’s (can’t perform a simple movement pattern) on any individual test. But guess what, if you have at least 2’s on all 7 tests, you already have a minimum of a 14.

Remember, the Functional Movement Screen is a filter, what are you trying to catch? I am primarily  interested in catching pain with movement as well as  the inability to perform a simple movement.

Ben Kazman J, Galecki J, Lisman P, Deuster PA, Oʼconnor FG. Factor Structure of the Functional Movement Screen in Marine Officer Candidates. J Strength Cond Res. 2014;28(3):672-8.

Recently, I tested a player in professional sports who had the following Y Balance Test and Functional Movement Screen scores.

Move2Perform Report High YBT Low FMS

Test 1 Graph

 Move2Perform Report High YBT low FMS

 

If you will notice, his Y Balance Test Lower Quarter scores were great – symmetrical and above the risk cut point for his gender, sport, and competition level. But his Functional Movement Screen was riddled with fundamental movement pattern deficits and asymmetries. This a classic example of why both tests are necessary for a more complete profile of the athlete’s motor control of body weight.

In an unpublished analysis of 1490 athletes/active individuals, we found 677 (45%) passed the Y Balance Test Lower Quarter and of those 677 that passed, 243 (35%) failed the FMS. So, if you only use the Y Balance Test Lower Quarter, you will miss about 16% of the athletes who are at risk of injury.

However, consider another athlete on the same team:

Move2Perform Report low YBT good FMS

Test 2 Graph

 Move2Perform Report Good FMS poor YBT

As you can see with this player, his FMS score was good (no zero’s or one’s). While he may possess movement competence as demonstrated by the Functional Movement Screen, he has deficits in his motor control capacity as measured by the Y Balance Test Lower Quarter. But with an anterior reach asymmetry and a composite score below his peers (other professional baseball players), he is at risk of injury. His dynamic left/right imbalance and decreased performance at his limit of stability is a substantial risk factor for injury.

If we go back to the analysis of the 1490 athletes/active individuals, we found that 535 (35%) passed FMS and of those 535 that passed, 253 (47%) failed the Y Balance Test Lower Quarter.  If you just use the FMS, you will miss about 17% of the total number of athletes who are at risk injury.

Thus, it is important to use both the Functional Movement Screen and Y Balance Test for a more complete profile of the athlete as well as the most robust injury risk prediction (see Lehr et al 2013). Or at a minimum, establish basic motor control competency with the Functional Movement Screen first, then move on to the Y Balance Test.

What do you think?

  • The Selective Functional Movement Assessment top tier testing reliability was examined in two ways:
    Click for larger view

    Click for larger view

    categorizing each of the 7 patterns into pattern into 4 categories (FN, FP, DN, DP) or by the criteria checklist (the criteria by which each movement is determined to be functional or not). Both methods demonstrated good to excellent reliability in raters who have experience with the grading (i.e. greater than 25 hours experience with the SFMA). Raters with only 8 hours experience had poor reliability. This speaks to the importance of training AND practice in clinically assessing movement (Juneau et al and Glaws et al)

 

  • An individualized corrective program based on movement deficits identified by screening improved collegiate softball players Move2Perform injury risk category. In addition, the FMS and YBT scores improved with significant difference from baseline to final testing in both screens. With regard to overall injury-risk category, there was a 31.2% reduction from high-risk to low-risk categories with this individualized injury-prevention program. The researchers suggested further risk reduction may have occurred if all of the players in the highest risk category (substantial risk) received one on one interventions (Erion et al)

 

  • A high percentage of athletes after ACL reconstruction cleared by the surgeon to return to sport did not pass even basic injury prediction tests including the Functional Movement Screen and Y Balance Test Lower Quarter. The authors stated, “progressive standardized tests of neuromuscular function may be beneficial to add to the interdisciplinary decision making process when returning patients safely to their prior level of sports participation” (Butler et al)

 

References

Erion A, Alm A, Hudson C, Matsel K. Athlete-Specific Corrective Exercises Improve Functional Movement Tests and Injury Risk Categories in a Collegiate Softball Team. Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1): A53-4.

Juneau CM ,Hewett T, , Glaws K, Becker L, Di Stasi S. Inter- and Intra-rater Reliability of the Selective Functional Movement Assessment in a Healthy Population. Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1): A53.

Glaws K, Juneau CM, Becker L, Di Stasi S, Hewett T. Intra- and Inter-rater Reliability of the Standard Scoring of the Seven Fundamental Movements of the Selective Functional Movement Assessment (SFMA) in Healthy Adults. Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1): A53.

Butler RJ, Mayer S, MD,  Garrett W, Taylor D, Moorman C, Toth A,  Queen R. Functional testing differences in ACL reconstruction patients cleared vs. not cleared to return to sports using clinical examination. Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1) A34

While there has been a lot of great information presented, here are a few pearls from the first day:

2014-02-04 13.03.39

  • Not surprisingly, wrestlers perform better than baseball players on the Upper Quarter Y Balance Test.  Just like the Lower Quarter Y Balance Test, norms and risk cut points need to be gender, age, sport/activity specific. Want more info in need for population specific norms CLICK HERE

 

  • Shoulder flexion ROM limitation may be a risk factor for injury in professional baseball pitchers. This was not presented as formal research, but was briefly mentioned as an upcoming publication during the morning throwing athlete session. I am intrigued.

 

  • Asymmetrical Lower Quarter Y Balance Test at 12 weeks status post ACL reconstruction identifies those who won’t pass hop testing at time of return to sport. This is important as it can identify early those who may need different rehab strategies before higher level (e.g. plyometric) activity can be performed

 

References

Garrison C, Wolf G, Bothwell J, Conway J, Thigpen C.  Single Leg Squat Symmetry at 3 months is related to Single Leg Functional Performance at Time of Return to Sports Following Anterior Cruciate Ligament Reconstruction. Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1):A50-51.

 

Myers HS, Poletti M, Butler R. Functional Performance on the Upper-Quarter Y Balance Test Differs Between Throwing Athletes and Wrestlers. Poster presentation. J Orthop Sports Phys Ther. 2014;44(1):170.

In a previous post, I discussed the importance of closed kinetic chain testing in a baseball player. A quote from one of the original reliability studies on the Closed Kinetic Chain Upper Extremity Stability Test (Goldbeck & Davies 2000) provides additional support for the need for closed kinetic chain testing:

“Typically, in clinical practice, a measurement or test is performed to evaluate the status of a particular parameter, and then, based on the test results, appropriate intervention strategies are applied to improve the deficit. Clinicians must ask themselves why closed kinetic chain upper extremity exercises are being integrated into treatment programs when no testing has been performed to demonstrate any deficits in those areas”

So, if you are doing rehabilitation in the closed-kinetic chain, you need to test in the closed kinetic chain as well: trunk stability push up, Upper Quarter Y Balance Test, plank, CKCUEST, and one-arm hop test.

Goldbeck TG, Davies GJ. Test-retest reliability of the closed kinetic chain upper extremity stability test: a clinical field test.  J Sport Rehabil. 2000;9:35-45.

Trunk Stability Push UpY-Balance Test - Infero Lat

In the last post, I discussed the importance of having a patient or athlete demonstrate that he has basic motor control competency and capacity in the closed kinetic chain. That way there are more data points to indicate that there is a solid foundation for sport specific skills. Now I will focus on selecting tests that can be used for the upper quarter. Please note, I used upper quarter versus upper extremity intentionally given the vital connection of the upper limb to the thorax.

Before listing specific tests, it is important to consider the testing order. Prior to higher level closed chain testing, there must be basic range of motion and strength. I do want to make special note of the importance of testing grip strength with hand at side, out front and full flexion and comparing bilaterally. Symmetrical grip strength in these positions indicates that the shoulder has enough stability to generate force through the hand. Try this and you might find some interesting results.

Once that is present, I feel comfortable progressing through an upper quarter testing hierarchy.

Functional Movement Screen Trunk Stability Push Up

Trunk Stability Push Up

While I don’t perform the Trunk Stability Push Up in isolation (I use all seven tests), I do feel it is important to mention it in the hierarchy of upper quarter tests. The TSPU requires symmetrical trunk stability, scapular stability, and upper extremity strength. Before advancing to higher level tests, I want to see the person score a 2. That means that from the bottom part of a push up position, the trunk comes off floor as one unit with no sag in lumbar spine (able to perform with thumbs in-line with chin (men) or with thumbs in-line with clavicle (women)).

Once this is normal, I want see that he has bilateral static stability through prone plank position for at least 10 seconds. Then I look at unilateral stability through holding the side plank for 10 seconds. Remember, I am not trying to test endurance with these tests at this point. Endurance, power, and agility come later in the testing hierarchy.

Y Balance Test – Upper Quarter

Of course, I have a bias here. I was actually resistant to creating an upper quarter test similar to the Y Balance Test for the Lower Quarter. But now, I actually appreciate the harmony of the Upper and Lower Quarter Y Balance test and I get a ton of information from both.

Y-Balance Test - Infero Lat

There are 2 published research studies (Gorman et al 2012, Westrick et al 2012) that specifically examine Y Balance Test – Upper Quarter. Both studies found the Y Balance Test – Upper Quarter to be reliable. In addition, both studies found there was no difference in YBT-UQ performance between dominant and non-dominant limbs. This indicates that YBT-UQ performance may serve as a good measure in return to sport testing when rehabilitating shoulder, upper limb, and spine injuries. Westrick et al stated:

 

“Similarity on the UQYBT between dominant and non-dominant limbs indicates that performance on this test using a non-injured UE may serve as a reasonable measure for “normal” when testing an injured UE.”

In our current research, we are also finding right/left symmetry on the YBT-UQ in professional and collegiate baseball players (including pitchers). So, I think if overhead athletes and healthy adults demonstrate symmetry on the YBT-UQ, patients should demonstrate symmetry before returning to sport/activity (or at least before discharge).

In the next post, I will go through higher level upper quarter testing.  This will cover testing for endurance, power, and agility including the 4 plank positions, one arm hop testing, and the Closed Kinetic Chain Upper Extremity Stability Test.

So you have decided to take the plunge — you are going to try some injury prevention with a large group or team. You have already talked with the coach and have some “buy in” (if you don’t, start here). Here are 5 things that will help make your injury prevention successful:

teamwork - ants

1. Start Small – Just like dieting, small incremental steps are key to permanent success. People hear that we test 150 athletes in 2-3 hours and give real time reports of performance, risk categories, and 3 corrective exercises for each athlete. However, this didn’t happen overnight. Just like water eroding rock over time, we gradually changed our injury prevention culture over several YEARS. If you start by simply setting a goal of making your injury prevention better than it was last year, you will gradually get there. Here are a few suggestions:

      • Start with a coach you have a good relationship with and one team
      • Select one or two tests to do (see below)
      • Ask injury history questions
      • Work with the individuals who had pain with testing
      • Be sure to retest those individuals to ensure the risk factors have normalized.

2. Categorize to maximize your resources – Particularly when testing large groups, it can be a daunting task to try addressing the risk factors you find. If you categorize individuals by their degree of risk (Lehr 2013), you can make the process more manageable.  Check out how a Division III college did it with their Body Armor Program.

3. It’s gonna take a village – I frequently feel like I am on an “injury prevention island”. With some discussion, I do find many like-minded individuals. Some have tried injury prevention strategies before  only to stop because they didn’t have good buy in. Others (particularly coaches) want to implement injury prevention, but don’t know how. Still others have misconceptions about how long it is going to take or how difficult it is. Just like other behavioral change, Start with Why to get people on board. When talking with a coach, discuss performance and durability benefits. For medical personnel, discuss keeping our athletes healthy and on the field.  Also, think outside of the box when assembling your team of testers.  Elicit the help of students (of any type: exercise physiology, PT, ATC, etc can help with the simpler testing), coaches (corralling the athletes), parents (ensuring forms are completed), and front desk personnel (data entry). They can all do something to help.

4. Use reliable, evidenced-based, predictive tests that can be completed quickly – Most frequently, I use injury history, Y Balance Test and Functional Movement Screen (I clearly acknowledge my bias here — I would love to hear what you use).

5. Start with Return to Sport Testing – Remember, previous injury is the most consistently reported risk factor for future injury so be sure you are using predictive, evidence based tests in your discharge protocol. Over the next several posts, I will take research based look at discharge testing and answer some commonly asked questions like:

    • What should the limb symmetry be for hop testing? (hint: it is NOT 90%)
    • What percent of athletes return to sport after ACL reconstruction?
    • Do strength and range of motion testing matter?
    • What does research tell us about basic movement testing?

So, if you are currently doing injury prevention, write down your goals for making your injury reduction strategies better than next year. If you haven’t started, utilize a few of the strategies to get started on a small scale. For those of you who have implemented injury prevention programs, please share your strategies with the group by commenting below.

When it comes to injury prevention, we are all excited, passionate and ready to get started only to hit road blocks: No one seems to want to give it the attention that it deserves. Coaches don’t want to give up valuable practice time, parents can’t fit it into jam packed schedules, and athletes, well, they are athletes!

Over the past 15 years, I have made many failed attempts at implementing injury prevention programs, so I would like to share with you what I have learned. After a great Twitter Chat with #solvePT, I decided to focus this blog post on talking with coaches and parents.

Fallen Tree Blocking Road

Some of the best injury prevention researchers in the world looked back at their injury prevention efforts with a huge cohort of female handball teams over a 10 year period (Mykelbust et al 2013). One of their key findings is that for injury prevention to be successful you “must have the coach as a “partner” in the process”. But how exactly do you do that?

Frequently, because of our passion, we provide too much information and end up sounding like a pushy salesperson. When talking with coaches and parents I suggest breaking it down into several steps:

  • Step #1: Ask, “Can I test your team/athlete to see how they are doing?”  Don’t promise too much. Just mention that there is some good research about the ability to identify athletes at more risk of injury and improve their performance. (Remember: researchers have found that the message should focus on both performance and prevention — also remember that if you are on the bench with an injury, you can’t perform!)
  • Step #2 After testing, don’t say anything. Wait for coach/parent to say: “How did they do?” Now you have some buy in because they are asking the question — you are not pushing information
  • Step #3 Tell them how they did: “I found these risk factors and research indicates that puts them at risk for injury.” Then be quiet. This is THE hardest part!
  • Step #4 Parent/Coach says “Well, what are YOU going to do about it?” I say smiling, “I’m glad you asked.” — Total buy in
  • Step #5 Present your evidence-based injury prevention strategy by changing the modifiable risk factors you tested

While these steps are the best way I have found to have the conversation, it is by no means 100% effective. I think the other key ingredient is persistence. Mykelbust et al said it best:

“persistent effort to promote injury prevention over several years, using every opportunity available”

It can take years to change the culture of any organization. In future posts, I will talk about specific implementation strategies. Sign up for this blog to be sure you get notified when it comes out.

I really want to hear from you. What strategies have you found to be successful to get people on board with your passion?

23 May 2013

Injury Prevention Programs for Groups

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Myklebust G, Skjølberg A, Bahr R. ACL injury incidence in female handball 10 years after the Norwegian ACL prevention study: important lessons learned. Br J Sports Med. 2013 May;47(8):476-9

After implementing ACL prevention programs in handball teams for over 10 years, the authors sought to answer the question of what made the injury prevention programs successful. They came to 3 main conclusions for successful programs:

  1. “must have coach as a “partner” in the process.”
  2. The prevention program was efficient
  3. The message “we delivered to coaches in seminars, through pamphlets, interviews and on our website, was no longer ‘may reduce injury risk’, but ‘will reduce injury risk by at least 50%’. This ‘specific’ information meets one of the Heath Brothers’ criteria for ‘sticky’ messages—messages that have influence.”

Finally, the authors concluded:

“Risk factor studies are necessary to identify the individual’s needs for special training and optimise the selection of preventive exercises. In the meantime, we suggest that team sports include prevention exercises in their warm-up, tailor the exercise  programme to the specific sport and focus on coach education as a key factor”

 

Asymmetries are common in the human body and can lead to a wild goose chase in musculoskeletal assessment.  But how do we know which asymmetries are important and will lead to injury? Well, let’s look at some common misconceptions as well as the research.

Wild Goose Chase

Common Misconceptions About Asymmetries

1.  If someone performs well at their sport with an asymmetry, the asymmetry doesn’t matter.

Who ever said that asymmetry IS related to performance? Asymmetry is related to injury risk, not necessarily performance. While I am concerned about performance, I am more concerned about keeping them in the sport and participating without being encumbered by injury.

 2. Asymmetries are only important if they cause pain.

I am mostly concerned with asymmetries that cause movement inefficiency or are related to injury risk. To me,  asymmetrical fundamental movement patterns will lead to injury or inefficiency (i.e. energy expenditure that is unnecessary for performance of the activity).

3. There is no research that indicates asymmetry increases risk of injury

Those who have an anterior reach distance asymmetry on the Y Balance Test (Star Excursion Balance Test) are at increased risk of injury in high school basketball and multiple collegiate sports (Plisky 2006, Lehr 2013)

Those who have an asymmetry on the Functional Movement Screen (Kiesel 2013 in press) are at increased risk of injury in professional football

Strength and flexibility asymmetries:

        • Athletes experienced more lower extremity injuries if they had knee flexor and hip extensor strength asymmetries (Knapick 1991Nadler 2001)
        • Eccentric hamstring strength asymmetries were at greater risk of sustaining a hamstring muscle strain. (Fousekis 2011)
        • Hamstring/quad ratio asymmetry (Soderman 2001)
        • Ankle strength asymmetry (Baumhauer 1995)

Asymmetrical landing patterns predict second ACL tear in previously reconstructed athletes (Paterno 2010)

Bottom Line: I really don’t put much stock into isolated bony asymmetries (e.g. torsions, misalignments, etc.), but I do feel that modifiable movement asymmetries that are related to risk of future injury are extremely important. Further, the literature is replete with studies that indicate asymmetries exist after pathology (Gribble 2013, Hewett 2013).  Since previous injury is the most robust risk factor for future injury, we owe it to our athletes to normalize these modifiable risk factors.

What do you think?

 


About Phil

Phil Plisky

I want to change peoples lives through dialogue about injury prevention research and return to activity testing.

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