A True Tale of Two Teams: Team #1
A soccer team wanted to reduce injuries. Well, not exactly. The real passion was provided by a local physical therapist who wanted to reduce injuries on this particular soccer team. The PT volunteered his time and implemented the FMS and Lower Quarter Y Balance Testing for this group. The first year it was a challenge simply to get the testing scheduled and completed. But each year, the testing got easier and eventually the Upper Quarter Y Balance Test was added.
Every year, the players received their Move2Perform reports with the risk category (Lehr et al) as well as 3 corrective exercises to perform. There was little buy in from coaches and athletes, little follow up and no re-testing occurred. After the 4th year, the athletic trainer was exceptionally frustrated as the injury rate was still sky high. He told a colleague, “The FMS doesn’t work. Players who score a 16 are still getting hurt! We need to do more and different screening.”
Fortunately, the testing data was kept and it was analyzed. Over the past four years, 17 athletes with preventable, time loss lower-extremity injuries were identified. Their Move2Perform category was then examined and these results showed that 13 of the 17 players were in the moderate or substantial risk category at the start of the season in which the injury occurred. Is the problem that the tests were not identifying the players who were at risk? No. The problem is that the athletes who were identified as at substantial or moderate risk for injury did not receive appropriate intervention strategies and re-testing.
A True Tale of Two Teams: Team #2
A baseball team wanted to reduce injuries. Well, not exactly. The entire sports medicine and performance team wanted to revamp their injury prevention system. They wanted something stable, reliable, and scalable. They hired a consultant to systematize their injury prevention. After working with the consultant, they elected to do the FMS and Y Balance Test and categorize athletes using the Move2Perform software. They created a mission statement and goals. After testing, they developed a strategy for each player to address the deficits found. They had a re-testing schedule and organizational accountability for the outcomes.
At the end of the season, they had one of the lowest injury rates in their history as well as one of the lowest injury rates among their peers. They found that if a player entered the season with deficits (in the higher risk Move2Perform categories), they were 4 times more likely to get injured. If they were able to improve the deficits and get the player into a lower risk category, they did not get injured. The next year, they had a plan to improve their testing, intervention strategy, and outcomes.
Both teams used testing for injury prevention. Why was only one team successful? Here are a few of my observations of the successful team:
- They started with Why: One team recognized that the best way to improve player performance was to keep them on the field in the first place (prevent injury). Each staff member from lowest level to highest level gave the same answer to the question: Why are we doing this?
“Last year, we had too many injuries that kept key players from performing their best.
We are doing this so everyone can stay on the field with top notch performance.”
- They had entire organizational buy in from coaching, strength and conditioning, rehabilitation, and medical staff. They owned and internalized the process. The system became part of their culture.
- They analyzed their current state: What was their historical injury rate? What were they currently doing? What was working, what wasn’t? What tests or screens were providing meaningful information? What things were they collecting because of tradition?
- They had a written mission statement and objectives. They effectively communicated why, how, and what they were doing.
- They use multiple risk factors and categorize their team members by systematically weighting those factors. They don’t rely on a single risk factor for their risk identification and intervention strategies.
- They financially invested in the system. When things are free, people don’t see as much value in them as when they purchase them.
- After testing, they had clearly written intervention strategies that were communicated among all involved parties.
- They monitored their outcomes and developed strategies for improvement.
- And finally, the successful team had a checklist throughout the continuum of care and across disciplines.
Bottom line: The successful team improved player performance by implementing systematic injury prevention. Future posts will expand upon each of the characteristics and describe implementation strategies. Subscribe here to be sure you receive future posts.
Have you identified other characteristics of teams successfully implementing systematic injury reduction and performance improvement? Add your comment below to help better our community.
12 Jul 2015
Please help guard your kids from their next ACL tear. Please.
As a father of 4 boys, protecting their health and wellbeing is of utmost importance to me. My wife and I believe sports participation offers our children physical, emotional, and leadership benefits. Unfortunately, sports injuries are costly both physically and emotionally. It seems that injuries are just part of the package. Or are they?
These injuries can be reduced. That’s right, we know how to predict and prevent ACL tears and all of the subsequent misery. We know how to prevent ankle sprains and other maladies. The real problem is that we just can’t get parents and health care providers to take action.
Numerous researchers, myself included, have dedicated their lives to injury prediction and prevention. So, what do we know? By combining multiple, easy to perform movement tests and other evidence-based risk factors, we were able to develop an injury risk algorithm that categorizes an athlete’s injury risk. We put the algorithm into a novel software application called Move2Perform, making injury risk prediction available to fitness and health care professionals globally.
A study by Lehr et al validated this algorithm in collegiate athletes. Lehr’s study demonstrated that athletes who were categorized by the Move2Perform software as being in the highest two risk categories were 3.5 times more likely to get hurt than their peers. Interestingly, no athletes who were in the optimal (lowest risk for injury) group were injured — apparently being “protected” from injury.
A similar algorithm has been developed for the U.S. military. Our ability to test and categorize many people quickly led a team of researchers to replicate the injury prediction in sports for the U. S. Military. The result was a 5 year research project called the MP3 study—Improving Military Power, Performance, through Prevention – which developed an injury predication algorithm for our service members. In addition, these sports and military algorithms are now being applied in the occupational setting.
But what can I do as a parent?
There are several steps parents can take to decrease their child’s risk of injury. Begin by embracing prevention. Like vehicles, bodies require preventative maintenance. Youth does not insulate your child from injury. A comprehensive movement “check up,” annually at minimum, is essential for musculoskeletal health.
In addition, here are 6 suggestions you can implement as a parent to help protect your child from injury (I will expand on each of these in subsequent posts):
1) Don’t have your child specialize in one sport too early or play too often. Using the guideline of no more hours per week in sports practice or competition then their age can solve a lot of problems
2) Find a provider using the best evidence available for your child’s movement screening
3) Be sure research-validated testing is performed pre-season and between sport seasons
4) Ensure that the risk factors identified during testing are corrected and verify that they have been corrected with re-testing
6) If your child does get injured, insist on standardized, evidence-based return to sport testing prior to being released from medical care. Being pain-free and “feeling great at practice” is not sufficient.
I realize it is hard to make injury prevention measures a priority between all of the practices and games, but identifying and correcting faulty movement patterns is essential to musculoskeletal health. We schedule maintenance for our cars to avoid inconvenient breakdowns. We see the dentist twice a year for precisely the same reason. It’s time we embrace the wonderful truth about injury prevention—injuries can be predicted and prevented.
Misconception #1: The Functional Movement Screen isn’t really a screen because it’s not sensitive
Misconception #2: The Functional Movement Screen is designed to be diagnostic
Misconception #3: The Functional Movement Screen results relate to how the person will perform under load or in competition
To read the entire post CLICK HERE
Disclosure: I teach an online Return to Sport Testing course for MedBridge. To find out why I recommend MedBridge CLICK HERE
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.
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.
26 Apr 2014
Recently, I tested a player in professional sports who had the following Y Balance Test and Functional Movement Screen scores.
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:
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:
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)
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:
- 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
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.
18 Oct 2013
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
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.
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:
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.