14 Mar 2014
In previous posts, I discussed why we would consider testing an athlete in an open-kinetic chain sport with a closed-kinetic chain test. Then, I discussed the hierarchy of testing and began with the Functional Movement Screen Trunk Stability Push Up and the Upper Quarter Y Balance test as basic tests of movement competency, motor control competency, and motor control capacity. Now we will examine another test that looks at capacity – the Closed Kinetic Chain Upper Extremity Stability Test.
The Closed Kinetic Chain Upper Extremity Stability Test is reliable and has some discriminant and predictive validity.1-3 The test is performed in a pushup position with the hands placed 36 inches apart on strips of athletic tape. The person reaches with alternating hands across the body to touch the piece of tape under the opposing hand. The number of cross-body touches performed in 15 seconds is recorded. The test can be modified by performing the test in the kneeling position.
It has also been suggested that the number of touches can also be divided by height to normalize the number of touches to each person. While this does give some normalization, the test is still not body relative since everyone has hands placed 36 inches apart (think about how hard that position would be for 5 foot tall gymnast compared to a 7 foot tall basketball player). In addition, a power score can be calculated by “multiplying the average number of touches with 68% of the patient’s body weight in kilograms, which is the weight of the arms, head, and trunk. That score is then divided by 15, which is the duration of the test in seconds. The power score reflects the amount of work performed in a unit of time.”
It appears that the CKCUEST does have some discriminant validity. In a recent study, researchers found that those with shoulder impingement performed substantially worse on the test compared to activity level matched controls.3 They also found the MDC to range between 2 and 4. What is interesting is that 15-25% of the “healthy” subjects reported shoulder pain after performing the test. This again speaks to the importance of having a hierarchy of testing (and maybe the number of people that consider having shoulder pain as normal).3 There is one prospective study that examines the predictive validity of the CKCUEST in collegiate football players.4 Researchers did a battery of strength, ROM, shoulder endurance, and CKCUEST at the beginning of the season on 26 players. The authors found that scoring less than 21 touches increased the likelihood of a shoulder injury during the season (5/6 of the injured players scored below 20 touches).4 While this test requires upper quarter stability, it is more of a speed/agility/power test as its measurement is touches per unit of time/height/bodyweight. I think the real value of the test lies in what one of the original authors describes as its ability to identify patients who were
“unwilling or unable to perform or developed pain during the test were not able to participate in their sport pain-free in the glenohumeral complex.”1
Bottom Line: Given the number of healthy people that have pain with the test and its potential predictive validity, it may have a place in the testing continuum to identify those with unreported pain/problems once lower level testing is complete (shoulder mobility, impingement clearing test, trunk stability push up, etc.). In addition, it can be used as one factor to determine that a person has the capacity to accept weight through one limb which is an important demonstration of stability and strength particularly after rehabilitation. Remember, this assumes all lower level testing has been passed.
1. Goldbeck TG, Davies J. Test-Retest Reliability of the Closed Kinetic Chain Upper Extremity Stability Test: A Clinical Field Test. J of Sport Rehabil. 2000;9(1):35-46.
2. Roush JR, Kitamura J, Waits MC. Reference Values for the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) for Collegiate Baseball Players. NAJSPT. Aug 2007;2(3):159-163.
3. Tucci HT, Martins J, Sposito Gde C, Camarini PM, de Oliveira AS. Closed Kinetic Chain Upper Extremity Stability test (CKCUES test): a reliability study in persons with and without shoulder impingement syndrome. BMC musculoskeletal disorders. 2014;15:1.
4. Pontillo M. Spinelli BA SB. Prediction of In-Season Shoulder Injury From Preseason Testing in Division I Collegiate Football Players. Sports Health. 2014.
Do dancers score differently than other athletes on the Y Balance Test Lower Quarter?
Researchers found that Y Balance Test Lower Quarter performance in collegiate dancers was superior to other athletes, with dancers demonstrating a mean composite reach score of 105%. “This research supports the findings of previous studies by demonstrating dancers’ superior dynamic balance ability compared to other athletes, thus indicating the need for YBT-LQ normative values to be established for dancers.” (Cole et al)
Do modifiable risk factors for injury still remain at return to sport in those with ACL reconstructions?
Another group of researchers (see previous CSM research post for the other research) found that deficits are present in athletes who return to sport post-ACLR. In particular, the star excursion balance test anterior reach asymmetry and prone heel height difference (a method to identify decreased knee extension ROM) were present at return to sport and clinicians “should consider using the SEBT to identify post-ACLR athletes who may be at increased risk for injury and decreased joint health.” (Stanley et al)
Does pain with clearing or movement tests predict injury in healthy active duty soldiers?
You bet it does!
In a cohort of 1455, “pain was present on 207 (14.2%) FMS movement tests, 176 (13.5%) FMS clearing tests, 56 (3.8%) YBT-LQ, 96 (6.6%) YBT-UQ, 93 (6.4%) 6-m hop tests, 80 (5.5%) triple crossover hop tests, and 13 (0.9%) ankle dorsiflexion. Pain at baseline movement testing was associated (P =.001) with future injury. The odds ratio of being injured in the upcoming year based on pain on movement tests was 2.0 (95% confidence interval: 1.6, 2.5). The odds ratio of being injured in the upcoming year based on prior history of injury was 2.1 (95% confidence interval: 1.7, 2.6).” (Teyhen et al)
Teyhen D, Shaffer SW, Butler R, Goffar SL, Kiesel KB, Rhon DJ, Plisky P. Pain and prior injury as risk factors for musculoskeletal injury in Service Members: A prospective cohort study. Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1): A39.
Stanley LE, Shanley E, Thigpen C, Padua D. Star Excursion Balance Test and Heel-Height Difference as Screening Tools in Athletes Who Have Returned to Sport Following Primary Anterior Cruciate Ligament. Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1): A65.
Cole HT, McGivern JM, Morejon A, Sudol-Horowitz T, Pivko S, Brooks G, Lusk MM. The Performance of Dancers on the Lower Quadrant Y-Balance Test (YBT-LQ).Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1): A67.
- 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.
22 Jan 2014
I spend a lot of time discussing that the Functional Movement Screen (FMS) and Selective Functional Movement Assessment (SFMA) are not intended to be sport specific or even “Functional” measures. The FMS and SFMA are used to determine if a person has the underlying movement competency to serve as the foundation for his or her activity.
So why are there age, gender, and sport/activity specific norms and risk cut points for the Y Balance Test? Isn’t that a contradiction?
When it comes to higher level testing (such as dynamic balance), there can be an activity specific balance adaptation that occurs. To see how this plays out as different norms and injury risk cut points, check out this short video
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.
I am frequently asked, “What tests are available when doing return to sport testing for a baseball pitcher?” When I start to suggest some closed kinetic chain tests like the Closed Kinetic Chain Upper Extremity Stability Test and the Upper Quarter Y Balance Test, I immediately get the next question of
“Why should I test someone in the closed kinetic chain when his sport is exclusively performed in the open kinetic chain?”
“Closed kinetic chain testing is not “functional” for a baseball pitcher, why do it?”
First, we must define the goal of testing. Is replicating the sport or activity that the person is returning to our goal? I am not sure I have the ability or equipment needed to evaluate a baseball pitcher that moves at over 8,000 degrees per second. In order to capture that speed accurately, sophisticated (and typically time consuming and costly) biomechanical analysis is required.
The problem is, even with that huge quantity of precise data, it does not tell us WHY the elbow or shoulder is in a certain position. Is it a problem with technique, or is it an underlying thoracic mobility or dynamic core stability issue? For that, I need different testing.
My goal in testing the upper quarter in the overhead athlete is to determine if the person has the fundamental mobility, stability, and motor control that is the foundation for human movement regardless of the speed. This foundation includes not only glenohumeral joint stability and scapular stability, but how that extremity integrates with the core.
Most clinicians would agree that basic range of motion and strength need to be present prior to sport. Beyond traditional goniometer and muscle testing, one of the best ways of evaluating an athlete that has adequate mobility and stability is through testing in the closed kinetic chain. If the athlete can demonstrate that he has basic motor control competency and capacity in the closed kinetic chain, I have more data points to indicate that he has a solid foundation for sport specific skills, like hurling a small projectile thousands of degrees per second.
I want to first see that he has bilateral static stability through plank and push up type positions. Then progressing to unilateral static postures like the side bridge. Ultimately, I really want to see how the person responds when challenged and deficits are typically best seen at the limit of stability.
What do you think about testing open kinetic chain athletes in the closed kinetic chain and what tests do you use? Let’s start a discussion.
The next test in our series on return to sport testing is the Star Excursion Balance Test. While many of you are familiar with the research regarding the test’s utility in predicting injury in the pre-participation setting, it seems to be less commonly implemented in return to sport testing. Remember, we are currently discharging our patients with modifiable risk factors for future injury.
So, how can the Star Excursion/Y Balance Test help us? You may have read the systematic review. But what amazes me is that in the original paper we reviewed 36 articles extracted from 1998 to 2010, and since then over 30 additional research articles were published in 2011-13 (for a total of over 60 published articles on the Star Excursion/Y Balance Test). Here is a summary of what we know:
- Reliable (Plisky et al 2009, Shaffer et al 2010, Gribble 2013)
- Predictive of injury (Plisky 2006, Lehr 2013, de Naronha 2012)
- Discriminant Validity
- Identifies chronic ankle and ACL insufficiency (Hubbard 2007, Hertel 2006, Hale 2007, Akbari 2006, Nakagawa 2004 Gribble 2004, Olmstead 2002, Herrington 2009, Delahunt 2013)
- Differentiates between athletes based on age, sport, gender (Plisky 2009, Thorpe & Ebersole 2008, Bressel et al 2007)
- Improves after training (Filipa 2010, Fitzgerald 2010, Leavy 2010, Eisen 2010, McKeon 2008, Hale 2007, English 2007, Bouillon 2009, Kahle & Gribble 2009, Rasool & George 2007) even in the elderly! (Khale et al 2013, Hosseini 2012, Sarvestani et al 2012)
- Improving Star Excursion Balance Test scores reduces injury risk (Steffen 2013)
There is no doubt in my mind that the Star Excursion Balance Test/Y Balance Test has the most research behind it compared to any other return to sport test. Most importantly though, it is the ONLY lower quarter test I know of that is reliable, predictive, modifiable AND improving performance on it reduces injury risk. Please let me know if I am missing a test that has ALL of those characteristics.
Ok, I agree I should be using Star Excursion Balance Test for return to sport, but what is considered a “passing” test?
Given that the Star Excursion/Y Balance Test is predictive of injury and that one of main goals with return to sport decision making is determining if the athlete is going to get hurt again, we should look at the studies that use the test to predict injury:
High School Basketball players (Plisky 2006)
– Players with anterior asymmetry of greater that 4 cm are at increased risk of injury
– Girls with a composite score (94%) in the bottom third of their peers are 6 times more likely to get injured
Collegiate Football Players (Lehr 2013)
– All injuries occurred in players with a composite score of less than 89% (Note that the composite risk cut point needs to be based on gender, sport, and age.)
Active College Students (de Naronha 2012)
– Posterolateral reach of less than 80% of limb length increase risk of ankle sprain. Interestingly, posterolateral reach of greater than 90% was protective of ankle sprain.
Collegiate Athletes (Lehr 2013)
– Those who had a previous injury and scored below the composite score risk cut point for their age, gender and sport OR had a greater than 4cm anterior reach asymmetry were in the high risk category
Bottom Line: Prior to return to sport (or at LEAST prior to discharge), your patients should demonstrate a symmetrical Star Excursion/Y Balance Test that is above the risk cut point for their peer group.
As we work our way through improving our return to sport testing, our first stop is at hop testing. Most rehabilitation professionals use some form of hop testing, but which hop tests should we use and what should our passing criteria be?
While it is important to use double limb hopping as part of the progression in rehabilitation, it is unnecessary for return to sport and discharge testing. In a study by, Myer et al double limb activities did not identify the unilateral deficits found after ACL reconstruction. Here are the unilateral tests supported by research:
•Single hop for distance
•6m timed hop — I don’t use this one. This is not solely based on published research (although the reliability is the lowest of the hop tests), but what I have observed clinically and through studies we have done. Basically, unless you use timing gates, your stopwatch trigger finger error is pretty close to any right/left asymmetries you would find (except in the cases of severe asymmetry — which the other hop tests would pick up)
•Triple crossover hop
•Hop & Stop — I really like the concept of this one and I am starting to use it more clinically. There are normative values and you know what a big fan I am of using population specific values to determine risk. Jeremy Boone has written about the hop and stop here
The above tests are reliable and modifiable (Munro & Herrington 2011, Reid et al 2007). I have not seen any studies demonstrating the injury prediction value of these hop tests (if you do know of such studies, please let me know) but they do have decent discriminant validity.
Criteria for Discharge and/or Return to Sport:
To me, the MOST important question is “What should the return to sport and/or discharge criteria be for hop testing?”
The most common return to sport criteria that I have come across in the literature is 85% and 90% Limb Symmetry Index (LSI). I believe neither of those is stringent enough. Remember, previous injury is the most consistently reported risk factor for future injury and we are currently discharging individuals with modifiable risk factors. So, on that basis alone, our standards should be higher.
But, let’s look at the research. Reid et al 2007 repeated hop testing on 4 separate time points after ACL reconstruction (16 weeks, a couple times more that week, and at 24 weeks post op) and found good longitudinal and concurrent validity for the four hop tests. However, consider this interesting fact from their research:
At 24 weeks post-op ACL reconstruction, the average overall Limb Symmetry Index was 88.5% and the average Lower Extremity Functional Scale score was 69.3. An athlete with a 69.3 LEFS would have moderate difficulty with the following activities
•“Your usual hobbies, recreational or sporting activities”
•“Running on even ground”
•“Running on uneven ground”
•“Making sharp turns while running fast”
If someone reported this much difficulty with these activities (I realize this is an “average” report but their LSI report is also an “average”), should she return to sport? Bottom line: In this study, 89% hop testing LSI equates with moderate difficulty with simple sport activities. Thus, 90% is not enough. Also, just because someone has returned to sport (which is what is typically considered “success”) does not mean that she is not at substantially increased risk of injury.
Finally, Munro & Herrington 2011 found that the average LSI for the four hop tests was 100% (98.38 to 101.61%.) and that 100% of healthy subjects have at least an LSI of 90%. Based on these results, the researchers advocate that the return to sport LSI criteria be increased to 90%.
Given our current re-injury rate, I suggest hop testing LSI should at least be above 95% and recommend it to be above 97%-100%. Do you think we can achieve this in rehabilitation? Do you think we should use 90% for return to sport and 97-100% for discharge?