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As my frequent readers know, I’ve written several posts in the past where I’ve investigated some of the research done on the Functional Movement Screen.  You can check out the four articles below to get up to speed.

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Interrater Reliability of the Functional Movement Screen

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Core strength: A New Model for Injury Prediction and Prevention

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Research Review: Can Serious Injury in Professional Football be Predicted by a Preseason Functional Movement Screen?

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Research Review: Can Serious Injury in Professional Football be Predicted by a Preseason Functional Movement Screen?

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In the near future I will provide my review of Gray’s book Movement and my final review on the FMS as a whole (I’ve honestly been meaning to get to this for some time).  However, today I wanted to share with you an interview I did recently with Dr. Robert Butler who is currently one of the principal investigators of the FMS.  My goal here is to provide some balance to the discussion and to share the current state of FMS research.

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Without further ado, let’s get at it!

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Mark:  Thanks for taking the time to do this interview today.  Could you please tell my readers a little bit about yourself and your background?

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Rob – Mark, it is a pleasure and honor to be able to participate in this interview. As far as my background, I am currently an Assistant Professor in the Doctor of Physical Therapy Division at Duke University as well as a Clinical Researcher for Duke Health Systems Sports Medicine Division.

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I completed my undergraduate degree at Marietta College with a degree in Biology. I then followed up with MS in Movement Science with a concentration in Biomechanics from Springfield College and received my PhD in Biomechanics and Movement Science from the University of Delaware. After completing my PhD, I completed a post-doc at UNC-Chapel Hill before completing my DPT at the University of Evansville.

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It was at the University of Evansville where I began working with the Functional Movement Screen through collaborative work with Kyle Kiesel. My research has focused on the role of functional movement outcomes in identifying and addressing movement dysfunction with regards to reducing injury risk, improving therapeutic outcomes, and reducing the rate of joint degeneration.

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I currently have 14 publications in peer-reviewed manuscripts and have had over 50 abstracts accepted for presentation at national and international meetings.

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Mark:  That’s excellent Rob!  You’ve recently been involved with some of the research on the Functional Movement Screen.  Can you talk a little bit about how this opportunity came about and your affiliation with the system?

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Rob – I was a student and a fellow faculty member with Kyle Kiesel at the University of Evansville and I originally rebuffed the idea of the screen as I went to tinker in the high tech motion analysis lab I directed. However, as I learned more about the system I began to appreciate the use of the screen in clearing the fundamental motor programs that we often attempt to retrain at a higher level in athletes who are having pain and seek out biomechanical based movement retraining. It quickly became the screen that all of the runners at our clinic would have to pass prior to higher level gait retraining, it was our blood pressure test for movement.

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We found that as the fundamental pattern issues resolved there tended to be less of a need for higher level retraining. This continues to be the notion with which I encourage the use of the screen. I never have had a formal affiliation with Functional Movement Systems until recently when I began to instruct some of their courses. In addition, Functional Movement Systems has never financially supported any of the research projects that we have published.

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Mark: Looking at all of the research that has been done to date on the Functional Movement Screen, what things do you think we can currently say we know about the system?

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Rob – I think we can say the screen is reliable between raters trained in the system. We found very high reliability in a recently developed 100 pt screen we use in a research setting which simply forces the rater to score each individual component of the test. I think this step-by-step grocery list approach addresses some of the questions you raised in regards to the reliability study.

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I think we can say that performance on the screen can identify individuals at a higher risk for sustaining an injury in the NFL, military and firefighters. We have two larger scale studies, one in the NFL (N =232) and one in firefighters (N=109), that are currently in review that address these gaps in the currently available literature. The study in the NFL will also be the first study to formally support the role of an asymmetry on the FMS and elevated injury risk in the scientific literature.

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I think we also can say that performance on the FMS is modifiable when using a movement based intervention program.

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I do want to touch a bit on the generic “elevated risk for injury” comment that tends to draw so much ire. Sometimes this comment is taken out of context and I hope this commentary will clarify. The elevated risk of injury in subjects =< 14 on the composite score is 2.2x based on our current study in review. It is not an end all be all number but it was statistically derived and not randomly fabricated by the research group.

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The factor that tends to be the strongest consistent predictor of injury is a previous injury; however, this factor is not modifiable. Teasing out this factor is often difficult from a research design standpoint; however, we recently were able to accomplish this in a prospective epidemiology study in collegiate athletes. The results of the study observed that poor movement was a much stronger predictor of non-contact lower extremity injuries in comparison with previous injury alone. We are working on the publication of these findings.

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That being said, no one that I work with is suggesting we have solved all of the non-contact lower extremity injury worries with this model, rather we have simply outlined some patterns that should probably be cleared to minimize injury risk. Our clients do not sit on the couch and as a result they have a risk of injury. The FMS gives us a consistent feedback loop to clear through and maintain motor programs in order to minimize our client’s injury risk when exercising.

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 Mark: What things do you think that we don’t yet know, but might in the future?  Can you tell us what research is on the horizon for the FMS or is awaiting publication?

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Rob – The one thing that continues to arise in the literature is that a prior injury is one of the strongest predictors of subsequent injuries. This suggests that something inherently changes in the motor program following an injury and at this point in time we have yet to establish rehabilitation protocols that normalize the effect of the injury that is being rehabilitated. We think that the FMS may be an integral component of normalizing movement patterns during rehabilitation from an injury. The addition of this model may allow for the factor of prior injury to be removed from the injury equation.  This large scale study can only occur following a series of other studies;  however, it continues to take up valuable space on the office white board.

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We also are not sure how changing the FMS scores effect injury risk and this is another component that we are currently researching. This is often one of the fundamental and appropriate critiques of the system, however to the best of our knowledge there are not many other systems that have shown this either, particularly in an efficient and individualized manner. The goal of the FMS model is to provide an efficient screening process that provides a systematic intervention scheme based on the results of the testing. The goal of the screen is to identify the weakest link in the chain which is a different paradigm in retraining compared to the majority of the group programs that are currently promoted.

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In addition, the goal is to utilize the system in 100s of people a day not 100s of people a year. To borrow from the cardiovascular literature again, it took researchers approximately 30 years from the time hypertension was established as being a risk factor for cardiovascular disease to the research showing that reducing hypertension actually reduced the risk for a cardiovascular event. However, physicians did not wait 30 years to develop models to monitor and reduce hypertension. They proactively addressed the modifiable risk factors to optimize the health of their patients. I feel as if this is a nice and appropriate corollary to the Functional Movement Screen and corrective exercise strategy except that the FMS assessment and treatment is cheaper, easier, and more accessible with less potential side effects.

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Another area that continues to be examined is the composite score cutpoints of the screen in different populations. I think the =< 14 serves as a good starting point but not an end all be all and I think this view point is shared by the majority of the Functional Movement Systems group. The evidence currently supports the specific =< 14 cut off in the certain populations it has been established in, however, we expect that the relevant cutpoints for elevated injury risk may differ across populations.  We are looking to establish relevant injury prediction cut points across recreational, amateur and professional athletes of different age groups and across sports. Other research will also expand to look at the loading of certain variables on the injury algorithm.

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It may be that in certain populations performance on certain components of the FMS may have stronger relevance to injury prediction than other components of the test.  That does not disregard the seven FMS tests and the FMS model rather it would serve to establish a set of specific thresholds for performance on the FMS in a given population along in the presence of general movement competency.

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Finally, we are looking at linking the FMS with other tests that have been related to an elevated risk of injury to provide a more robust model for injury risk identification. It is likely that multiple tests that have independent movement constructs from the FMS will provide a more complete assessment to provide the optimal feedback to individuals who work in the realm of injury prevention.

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Mark: Now I know you were a little miffed about some of the comments about on my most recent review of the FMS research.  Please feel free to take a second to address some of these comments.

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Rob – I cannot recall my initial thoughts on this, however, I think the overlying concept that people have a difficult time with until they use the screen is that the FMS is a filter to catch large scale movement dysfunction not 2 degree differences in movement patterns.  The goal is to establish basic movement competency, to get your movement BP to 120/80. Why is it okay for a 14 year old to lose the ability to deep squat when in a 2 year old it would be a medical emergency?

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Part of it boils down to a lack of standards for basic movement competency. There are a number of research studies that have associated mal-alignment and poor movement with injury and pathology using much more precise and sophisticated equipment. This is one of the reasons why I feel the screen is often dismissed at first site…. It has to be more expensive to be meaningful… the course has to cost more to be worthy of my time …. my patients/clients could pass that test easy. These are often the comments reflected back to the screen.  My response to these lines of comments is fairly standard… “Perfect, then if you are interested just start collecting the FMS data and just see what happens.”

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The screening process is outlined in the reliability study (Minick et al., 2010, J Strength Cond Res) and Gray discusses how to build your own kit in “Athletic Body and Balance” for less than $20. All the information is out there for someone who wants to learn and incorporate the screen. The uber-transparency of the model is one of the reasons I am drawn to it. In a world of rehabilitation where there are often closed door assessments and jargon laden evaluations it is nice to have a model for all to understand and talk about at a common level of understanding across disciplines.

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If all the screen is used for is a standardized way to assess basic patterns of movement that were imperative in the neurodevelopmental process then I think the screen has accomplished a great deal. The importance of these fundamental patterns become more clear everyday as my two girls learn to defy gravity from the ground up and balance their own dual pendulum setups as they explore their everyday lives.

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Mark:  And finally, where do you think the FMS is most useful for the average trainer who is about to start training a new person?

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Rob – I think the screen gives everyone (you, the client, the client’s family, the client’s MD, a client’s MD in another country) an idea of where the client’s program is headed and why it is headed in that way with regards to the client’s plan of care.  I love the fact that health care providers do not have to speak the same language to talk movement.

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The screen also gives the patient some specific goals that they can often self-assess.  My patients often want to know we they aren’t running, jumping, doing kettlebells for Turkish getups, etc. during therapy.  I often will have a rationale in my mind as to why we are not doing these activities and when I explain the rationale for this it often falls on deaf ears. However, the second I give them the criteria of a wall squat with hands overhead and hips below parallel prior to starting plyometrics it tends to stick with the individual to a greater degree and the patient tends to become more engaged in the pursuit of the goal.

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I love empowering my patients to move better and to screen themselves in whether or not they are making gains.

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Mark:  Awesome!  Thanks for the interview Rob.

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Rob – Mark, thanks for your time and patience as I put this together. I hope this interview can provide some open dialogue with regards to the screen and what it can and cannot do. I look forward to speaking with you more in the future as we all aim to provide the best care and information to the clients and patients we serve.

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Like this interview?  Please share!

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What do you think?

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I’ve obviously been a crusader looking at the usefulness of the Functional Movement Screen and to date I think I’ve been pretty fair in my reviews of the research on the topic.  However, a friend of mine recently flipped me the following information (which I can only assume is from some kind of Functional Movement Screen newsletter) and it downright pissed me off.  Check it out!

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Weekly Update!
13 October 2010

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FMS returns this week to some unofficial reporting by Mr. Linwood Cook. Mr. Cook found the results to be:

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After week # 5 in the NFL, Functional Movement Screen NFL Teams had a win 64% win rate, or .6444.

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The NFL Teams who do not use the Functional Movement Screen, their win rate of 45%, or .4478.

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As of Week # 5 that is a 20% better win rate for NFL Teams using the Functional Movement Screen on a regular basis.

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Thanks Mr. Cook!

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Here are some great NFL studies that help support stats just like these!

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And then they go on to link the study I discussed yesterday and this study that I reviewed previously.

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While the win/loss percentages were obviously more observation than anything, I resent the fact that whoever is producing these emails is backing up these observations with studies that are completely unrelated to performance measures in any way.

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I feel terrible for the young fitness professional who has no formal instruction in research methodology and is perhaps too intimidated to read journal articles so they are at the mercy of those who market to them.

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While I certainly have no beef with presenting the research that has been done, I think that presenting it in this way is downright shady.  We bash supplement companies all the time for taking research out of context and bending statistics to make them look more favorable than they actually are.  How is this any different?

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I’ll elaborate on this more when I eventually write my final post on the Functional Movement Screen as a whole, but for now I will say that I think the FMS offers some good things that I think could be of use to any fitness professional.  But I also think that how the FMS is marketed (as seen above) is sometimes out of line with how many professionals are actually using it.

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Do you think I’m way off base here?

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1.  Did the pendulum swing too far?

This is actually a bigger notion than I can possibly cover in a single bullet point, but looking at all the stuff that has come to the forefront of the industry I’m starting to think we’ve just become way to focused on dysfunction.

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2.  Doing it Backwards (not what you think you pervs)

Imagine if you went to the gym, walked on the treadmill to warm up, did some static stretching, rocked out a crazy intense workout including exercises on guided motion machines and isolation exercises like kickbacks and curls in conjuction with your squats and deadlifts.  Imagine you used a body part spilt training program.  And instead of intervals you did steady state cardio for 30 minutes afterward.

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The would be no screening, assessments,  breathing pattern drills, rolling patterns, foam rolling, or mobiliy drills.  But you were consistent, trained hard, and did so 3-4 days per week.

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Then imagine that you didn’t take any supplements and only hit 0.8 grams per pound of protein daily.  You also didn’t eat every 2-3 hours, didn’t fast for a day at a time, or even a portion of every day, but you did maintain a moderate calorie deficit every day.  You didn’t eat everything organic or free range, but you did try to eat mostly whole food and limit obvious junk.

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Would we not get stronger from the program above?  What about leaner?  Would we end up injured?  My guess is yes, yes, and probably not.  Sometimes I’m tempted to do everything “wrong” just to make a point that perhaps we need to focus on the fundamentals before we start stressing about the details.  If you’ aren’t training hard, eating well, and being consistent you can pretty much scrap the rest because you’re wasting your time.

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3.  If your parents are alive…go hug them.

I miss my dad every day.  You never know when they’ll be gone.

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4.  Wake and Shake

Here is a link to a great blog post by Nate Green talking about his morning protein shake.  In it he asks for a few protein shake recipe ideas from his readers and they come through…big time.  My advice, check out the post and comments section.  Print and stick on the fridge and you’ll have a great list of ideas for the coming few months.

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5.  Don’t Sleep on Your Stomach

Lying in this postion can put your lumbar spine in an excessively extended position for a long time.  If you have back pain that is exaggerated by leaning backwards and improved by bending forwards this point is especially true.  Sleeping on your back with a pillow under your knees or on your side with a pillow between your knees will help to maintain a neutral spine.

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6.  How to Train for Power

Bret Contreras just posted this article on his blog last week and I think it provides a lot of really good insight on how we should (or should not) train for power.

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7.  I finally hit the newsstand mags!

I just received word last night from my friend David Barr that I’ve been featured in this month’s issue of Muscle and Fitness.  I’m totally stoked!

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8.  I have a weird fascination with making it into Men’s Health Magazine. 

I don’t know why, but when I started reading that magazine years ago I said to myself “I’m going to get published in here”.  By the end of 2011 I intend to be in that magazine even if I have to drive around the country and stick leaflets into every copy.  Just kidding.  Sorta.

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9.  New Sahrmann Text

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Just in case you didn’t know, Shirley Sahrmann has a new book out on October first!  Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines.  Should be interesting as her first text largely shaped my understanding of training.

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10.  Show & Go Sale is Ending

Today is the last day to get my friend Eric Cressey’s new product Show & Go at an introductory rate.  Don’t miss out as the price jumps at midnight.  And remember that there is a money back guarantee so if you’re on the fence you might as well get it.

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Bonus Randomness:  Little Known Fact

When Moses climbed Mount Sinai the Lord actually handed him THREE stone tablets.  The first two contained the ten commandments.  The third contained the 7 exercises of the Functional Movement Sreen.  Moses went on to live for centuries, moved to the United States, shaved off his beard, and changed his name to Gray Cook.

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In fact, Jesus wasn’t crucified because he was the son of God, but because he openly denounced the FMS.

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True Story.

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By the way, I think I’m going to hell for that one.  And FMS folks, I’m just kidding.  Don’t bomb my house.

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1)  Recently I had a discussion with Bret Contreras about a client I had several years ago who was experiencing lower back pain.  At the time, I was reading Eric Cressey and Mike Robertson’s stuff and got my client to stretch his hip flexors, strengthen his glutes, strengthen his abdominals, etc.  What I failed to realize that this was the solution for those with ANTERIOR pelvic tilt and/or extension based pain.  My client had POSTERIOR tilt that was made worse with flexion.  I actually made his pain worse!

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I later worked to strengthen his hip flexors, lengten his rectus abdominus (think cobra stretch), lengthen his glutes, and stretch the hamstrings.  Fixed the problem in short order.

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Take home lessons:

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- Assess your client and make sure that the method you are using is the right one . Eric and Mike had a great protocol, but I was using it on the wrong person.  (My fault, not theirs)

 - If you’re wrong, admit it and make changes accordingly.

- You will almost certainly learn something after talking with Encylopedia Bret-annica.

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2)  Speaking of Bret, he posted a great interview with my good friend Aaron Schwenzfeier.  Aside from having a name that is impossible to spell (I always cut and paste it when I have to write it) Aaron is a wicked smart dude and I’ve been following his stuff for over a year.

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Recently THIS POST by Aaron caused quite a stir in the comments on my Facebook page and I’m curious to hear what you think.  Should we have some sort of mimimum standard for physical fitness to graduate high school as we do with other more academic subjects?

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3)  I have been lucky enough to recieve a sneak peek of Eric Cressey’s new product that is to be released next week.  I’m only a few pages in, but a brief scan has led me to believe that this is going to be a great product for anyone interested in gaining strength AND looking the part.  I’m hoping to be able to lure him on here to ask him some questions about the new program in the near future so if you’ve got anything you want me to ask Eric about getting wicked strong let me know in the comments below.

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4)  I am also currently reading Movement by Gray Cook, playing with my new Rotator, and reviewing Rick Kaselj’s Muscle Imbalances Revealed product that also features Mike Robertson, Bill Hartman, Eric Beard, Kevin Yates, and Dean Somerset.  On top of that I’ll possibly be checking over the lit review on Mike Robertson’s upcoming product as well.  Suffice it to say that I’ve got a lot going on these days on top of my usual chaos. 

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The good news is that after I’m done checking out a product I’ll be able to share my thoughts with you.  The bad news is that with some many things to review, I might start to be percieved as one of those internet marketer types who is strictly in it for the Benjamins (that’s dollars for all of you who aren’t down with my gangsta lingo).  So let me reassure you right here and now that you will NEVER see me endorse a product that I do not support or at least think is worth reading, watching, or purchasing. 

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I honestly figure that this should be obvious since I’ve openly bashed the very popular book Crush It in this post and questioned the even more popular Functional Movement Screen.  To me it should be pretty apparent that I don’t just jump on the affiliate bandwagon to score a few bucks.  But if I do like a product you’ll see a glowing review from me because I consider it part of my responsibility (as someone who has access to a lot of these products) to separate the good products from the garbage.

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Moreover, if I post an affiliate link from I’ll let you know so you’ll have to option to purchase directly from the person who created it if you prefer.  Of course, my family might go hungry if you don’t buy it through me…but don’t feel guilty if you go the other route.  *cough, cough*  I feel so weak… 

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Bottom line: You’ll always get the straight truth from me and I won’t put my name behind something that sucks…unless it is a really good vacuum.

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5)  My wife and I have b en reading some funny stuff at a site we’ve discovered recently and I think THIS is the funniest article on the site.  I laugh so hard that it makes me pee a little every time I read it.  On the other hand, my wife thinks THIS article is funnier.  Which one do you think is the best?  Note: Don’t read the stories if you’re easily offended.  The guy is a little abrasive…and by “a little” I mean “a lot”.

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6)  This is AWESOME!

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 So I’m all over the map today.  Throw down your comments and let me know your thoughts.  Heck, if you’ve got something else on your mind let’s hear it.

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Recently I’ve undertaken the task of reviewing some of the research on the very popular Functional Movement Screen.  Previously I’ve reviewed the Interrater Reliability of the Functional Movement Screen and Core strength: A New Model for Injury Prediction and Prevention.

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Today I’ll be taking on the 3rd of 4 studies I hope to review.  After the final review I’ll talk a little bit more about my overall impression of the FMS and how I believe it should be used.

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Can Serious Injury in Professional Football be Predicted by a Preseason Functional Movement Screen?

Kiesel K, et al.  North American Journal of Sports Physical Therapy Aug 27, 2:3

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Background

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Risk factors for injuries in high school and collegiate football include previous injury, body mass index, body fat percentage, playing experience, femoral intercondylar notch width, cleat design, playing surface, muscle flexibility, ligamentous laxity, and foot biomechanics.  However, injury risk is likely a combination of many of the above.

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Further, evaluation of isolated risk factors does not take into consideration how the athlete performs functional movement patterns required for sport.  The goal of this study was to examine functional movement scores (assessed by the FMS) and to determine the relationship between professional football players’ score on the FMS and the likelihood of serious injury.

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Methods

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FMS scores were obtained prior to the start of the season for 46 professional football players.  A receiveroperator characteristic curve the FMS score was used to predict injury during one complete football season.  For the sake of this study, injury was defined as membership on the injured reserve for at least 3 weeks.

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A dependent t-test was used to determine if a difference existed between of the FMS scores of those who were injured versus those who were not.

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Sidebar – Definitions

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To have a clear understanding of the methods and the results of this study a brief discussion is needed to definte sensitivity, specificity, and how these are used to create a ROC curve (receiveroperator characteristic curve).

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Sensitivity is basically the power to detect a true positive.  For example, if you were to go through a scanner at the airport to detect for metal it would be very sensitive to decrease the likelihood that someone were able to slip onto an airplane with a weapon.  On the other hand, the scanner doesn’t have very high specificity in that it will sound for almost any piece of metal not just weapons.  In this case, a high sensitivity is most important because it is important that weapons do not sneak aboard the aircraft.

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A dog trained to sniff for narcotics would have a high specificity since only those carrying drugs would need to be stopped.  If the dog didn’t have a high specificity for a specific substance, but was highly sensitive it would possibly alert people needlessly to any scent and make the purpose of having the dog useless (since every bag would have to be checked anyway).

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In a perfect world every test would have 100% sensitivity and 100% specificity (i.e., identifying every weapon at the airport without going off for every other piece of metal), but this is rarely the case.  There is usually a tradeoff between one and the other and the ROC curve plots sensitivity against specificity to determine the ideal cutoff number to use to maximize both.

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With the FMS the the cutoff was chosen using the ROC curve such that the test correctly identifies the greatest number of athletes at risk of injury (true positives) while minimizing incorrectly identifying athletes not at risk of injury (false positives).

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Results

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A score of 14 or less on the FMS was able to predict injury with specificity of 0.91 and sensitivity of 0.54. 

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The test had a very high specificity indicating that the majority of people with a score below 14 had a greater chance of injury.

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Those with a score under 14 that got an injury = 7

Those with a score under 14 that didn’t get an injury = 3

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Unfortunately, the test had a only a moderate sensitivity so it did not detect those with a score over 14 who did experience an injury.

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Those with a score over 14 that got an injury = 6

Those with a score over 14 that didn’t get an injury = 30

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In other words, the bulk of the people with an FMS score over 14 did not get an injury and the bulk of those with a score under 14 did.  Using something called an odds ratio the authors determined that the likelihood of injury was 11 times more likely if the player had a score below 14 on the FMS.

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However, 6 people that did have a score higher than 14 did end up getting injured.  These ones were missed by the screen.  In fact, it failed to identify almost as many people as it did identify as being at risk.

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Funding

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None declared, but I believe at least two of the authors have affiliation with the FMS.  (Not that there is anything wrong with that, but I would declare this as a possible conflict of interest.)

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My Thoughts

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All in all I think that the FMS did a great job of determining that those with a score less than 14 were at risk for injury.  In terms of practical application, these players could have been flagged for specific work with a fitness/rehab professional.  On the other hand, the test wasn’t sensitive enough to detect risk of injury such that 6 athletes slipped through the cracks and ended up being injured without this being detected by the screen.

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Unfortunately, there was no differentiation between the types of injuries that landed people on the reserve list so it is possible that some of the injured athletes suffered from contact injuries that could not have been predicted by any test or screen.  Perhaps if contact injuries were ruled out (since you can’t really test for these) the FMS would have proven to be more sensitive.  Then again, maybe some of those with a score below 14 suffered contact injuries as well.  It would have been interesting to see if the results were different if these types of injuries were excluded.

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It is also possible that one reason the FMS predicted injuries so well below the score cutoff of 14 with this group is because it is the same group whose results were used to create the cutoff in the first place.  Only future research will tell if this pass/fail cutoff is equally as effective for other groups.

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Summing Up

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The FMS indicated correctly that those with a score less than 14 were more prone to injury.  However, the results of the present study indicate that the FMS may also miss equally as many people as it detected (which may be the reason why the pass/fail score for the FMS when it is typically used is actually lower than this).

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It would also have been interesting to see which of the individual scores within the FMS were most related in injury.  Since the FMS typically suggests that side to side imbalances are most important to address, it would have been nice to see this data to see if this hypothesis holds true.

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In the end though, the FMS does appear to effectively predict injury in this below a value of 14 in the group studied.  It does not catch all injuries and as such is not a perfect screen, but effective at picking out some who are at risk.  And since the results are those of professional football players, we should be careful when generalizing them to other populations.

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What do you think?

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A little while back I posted a review of a study looking at the interrater reliability of the Functional Movement Screen.  Today I’ll be looking at another study on the FMS to further elucidate the research that has been done on this popular system.

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Again, I’m not trying to rip anyone apart here.  I’m primarily looking the the research for my own benefit and in doing so have decided to share it with you.  If you care to read this study for yourself you can get the full text for free at the top right hand of the page HERE.

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Core strength: A New Model for Injury Prediction and Prevention

Peate WF, et al.   Journal of Occupational Medicine and Toxicology 2007, 2:3.

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Background

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Injuries to firefighters are among the highest of all occupations.  Research suggests that decreased core strength may contribute to injuries of the back and extremities, that training may decrease musculoskeletal damage, and that core stability can be tested using functional movement methods.  The purpose of this study was to use the Functional Movement Screen to better assess the risk of firefighter injury due to functional movement performance, and to decrease injuries by using that information.

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Methods Part 1: Screening

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Functional Movement Screen conducted on 433 active firefighters.  Analyzed correlation between FMS scores and data from fire department database including injury history, age, gender, tenure, and rank.

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Methods Part 2: Intervention

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Firefighters underwent 3 hour seminars (actual number attended by each firefighter hard to determine based on the way the study was written) covering causation and prevention of injuries.  During seminars each firefighter demonstrated proper body mechanics in sample work settings and taught how to minimize spinal load during work situations.

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“For example, firefighters were instructed to use an outstretched arm held against a firm surface as a prop to decrease mechanical load on the back when the firefighter’s spine is in lumbar flexion.”

Subjects were taught how to activate their transversus abdominis as well.

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“Participants were shown that muscle’s location in the anterior abdominal wall. Photos of various methods of recruiting and strengthening the TA with written explanations were provided, along with verbal reinforcement of the material.  Once the firefighter demonstrated competency in basic TA muscle tightening, physiotherapy balls and dowels were employed to challenge the firefighter in different positions that mimicked firefighting tasks.”

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Core exercises included three basic models which are similar to hamstring pushups, hamstring pushups with the upper back on a ball (hip thrusts?), and hamstring pushups with the feet on a ball.  Arm movement was added using weights of various amounts.  A detailed explanation of exercise variations, progressions, and how loading was used is lacking in this paper.  There are a few photos, but you’d be hard pressed to repeat this protocol by just reading the article.

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Injuries after one year were compared to injuries in the year previous to the addition of the intervention.

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Results Part 1: Screening

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Increasing age, rank, and tenure was associated with a lower functional movement score using linear regression.  After adjusting for age and using multiple regression, those with a previous injury tended to score an average of 0.24 points lower on the FMS, but this relationship was not significant (p = 0.25).  When the scoring on the FMS was observed as a pass or fail score (for some reason they said a fail was below 16) the odds of failing the FMS after having a previous injury was 1.68 times greater based on multiple logical regression (p= 0.033).
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Results Part 2: Intervention

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Compared to the previous year, lost time due to injuries was reduced by 62%!  The total number of injuries was reduced by 44%.  Injuries to the back and upper extremities were reduced, but injuries to the lower extremities were not reduced by the intervention.
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Funding
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Administration of the Tucson Fire Department
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My Thoughts

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I’ve noticed that this article is frequently used to support the Functional Movement Screen as a tool for screening for injury risk prior to physical activity.  However, when you look at the outcomes, the FMS was only able to determine that the risk of injury increases with age, tenure, and rank (the latter two are also typically related to age).  I don’t think I’m going out on a limb to suggest that most people could have told you this before even running the FMS.

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Although the authors do mention that there was a relationship between FMS score and previous injury based on linear regression, this relationship totally disappeared when corrected for age which appears to the major determinant of injury in this study.  The authors make a point of mentioning that they were indeed related but shy of statistical significance using multiple regression.  However, the p value (a measure of statistical probability) was 0.25 which is a LONG way from statistical significance at 0.05.  I would think it is fair to say that there is pretty much no relationship between FMS and previous injury in this study once you control for age.  Changing the FMS to a pass or fail criterion did make it better for determining risk after an injury.  As was mentioned earlier though, you don’t really need to do this if you just look at age as the primary predictor.
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I have also seen this study referenced to support the idea that the interventions based on the FMS are effective for injury prevention.  Taking a look at the study though, there are a few errors with this assumption.
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- The FMS was conducted at the beginning of the study and there was no follow up testing at the end to determine if there was an improvement in FMS score related to the 62% reduction in lost time due to injury.

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- The intervention had nothing at all to do with the FMS.  Everyone virtually received the same intervention regardless of score on the testing.  I’m no expert, but I’m pretty sure this isn’t how the FMS is supposed to be used.

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- There were other factors within the intervention besides the physical training.  Subjects were taught about injury mechanisms, bracing, and how to move in the work environment.  Personally I agree that this is a great way to intervene to make a larger difference in the safety of the firefighters.  However, from a scientific perspective, it introduces a whole bunch of other variables that could have lead to decreases in injuries that had nothing to do with the FMS.

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- There was no control group.  Injuries were compared to previous years which makes sense from a operations perspective, but when doing a scientific experiment a group not recieving treatment is usually run alongside the group that does.  In this case, it wasn’t done making comparisons in injury rates pretty difficult.  Again, a 62% decrease in lost time is excellent, but it could be due to factors beyond the intervention itself (i.e., less fires this year).
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Summing Up

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At the risk of pissing off a lot of people, I’m going to suggest that the FMS did not play an integral role (actually any role at all) in the improvements seen in this study.  Moreover, age was seen to be the biggest predictor of future injury which could technically be used alone instead of having to run the FMS on such a large group each year.

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As far as the Functional Movement Screen is concerned, the intervention doesn’t really matter because they weren’t really linked in any way.  That said, if you’re a firefighter, you might want to find out what these people are doing because it just may prevent you from experiencing an injury.  If you’re a firefighter and you’re a little older, you might want to consider a good accident benefits plan.

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What do you think?

Okay…it has been a while since I posted one of these, but I figured I’d drop a couple things I think are worthy of reading.

1.  Optimal Rest Intervals for Strength and Hypertrophy

 So you’ve probably been told that long rest intervals during training are important for strength and shorter rest intervals are for hypertrophy.  Well, I just found this site this week and Bryan Chung (who writes the blog) takes a solid look at a study that is examining these very things.  He’s not a coach or trainer, but he is a medical science researcher and sits on the board for the Clinical Journal of Sports Medicine so he knows his stuff.  Check out the excellent research review HERE.

2.  Movement

As my readers probably know, I can be a little bit of a doubting Thomas when it comes to training and nutrition related information.  At the same time, I can appreciate when someone has contribued a lot of great stuff to this industry and I’m interested to see what Gray Cook will present in his new book Movement.  Recently Laree Draper posted the following three posts by Gray Cook on her blog and I think they made for some great reading.  Check out parts 1, 2, and 3.

3.  Webinar Notice

My friend (and PhD Candidate) Mike T Nelson has just posted a sale on three webinars this week and time is ticking as this is a limited time offer.  Although I have yet to review them, I’m excited to hear what Mike is going to say so I thought I’d share this with my readers as well.  Apparently there is a sport supplement review, a discussion on metabolic flexibility, and another on the neurology of movement.  If you’re interested you can check out his site HERE.   (Note this is not an affiliate link)

That’s it for me.  What are you reading?

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Anyone who reads this blog regularly knows that I’m a big fan of assessments prior to training and repeat assessments along the way to ensure results are coming as desired.  Recently though, it seems that the Functional Movement Screen which was created by Lee Burton and Gray Cook has become extremely popular among my colleagues in the fitness industry.

If you’re not familiar with the Functional Movement Screen, here’s a little excerpt from their website describing the system:

“Put simply, the FMS is a ranking and grading system that documents movement patterns that are key to normal function. By screening these patterns, the FMS readily identifies functional limitations and asymmetries. These are issues that can reduce the effects of functional training and physical conditioning and distort body awareness.

The FMS generates the Functional Movement Screen Score, which is used to target problems and track progress. This scoring system is directly linked to the most beneficial corrective exercises to restore mechanically sound movement patterns.

Exercise professionals monitor the FMS score to track progress and to identify those exercises that will be most effective to restore proper movement and build strength in each individual.”

In short, you do 7 movements, get scored, and based on the outcome your potiential issues are identified and your training program can be designed.

 
Being the skeptic I am, I had to consult the research to determine what has and hasn’t been studied about the FMS.  And while I do believe that not everything worth doing is necessarily validated by science (yet), I’m also cautious when I see a pendulum swinging in one direction and when a great number of people are on board. It seems to me that the FMS has been accepted with little discussion as to whether it is valid or not. The more people that jump on board, the less people are apt to question it (especially when those people are big names).

So I’m not saying the FMS isn’t valid or useful or trying to discredit Lee, Gray, or anyone else who uses the system.  The next few posts are simply meant to be an examination of the existing body of scientific study on the FMS.  More to the point, I’ll be reviewing only the peer reviewed studies that have appeared in journals and not the unpublished stuff that is available on the internet (including at least one doctoral dissertation and a couple conference poster presentations).

Without further ado, let’s get to the first study.

Interrater Reliability of the Functional Movement Screen

Minik KI, et al.  J Strength Cond Res. 2010. 24(2): 479-486

While this isn’t actually the first published study on the movement screen, I thought it was important to present this first as it is indicative of the reliability of the scoring.  In a setting where different individuals would be scoring the FMS, you would need for them to be scoring the same way or the tool would be a lot less useful.

Background

To reduce injury risk, sports medicine professionals have begun to focus on improving movement patterns as opposed to focusing on rehabilitation of a specific joint.  The Functional Movement Screen has been put forth as a potential screening tool for these movement patterns.  The goal of this study is to establish interrater reliability of the FMS by comparing expert raters (who took part in the development of the FMS) with novice raters (who have completed the standardized FMS training program).

Methods

Forty students were filmed performing each of the 7 movements in the Functional Movement Screen.  Each of the subjects’ videos were then viewed by two expert and two novice raters and each of the 7 movements was independently scored as a 0, 1, 2, or 3 using the FMS criteria.  The scores were then compared using the weighted Kappa statistic.

Results

The pair of novice raters demonstrated excellent agreement on 6 of the 17 test components, including the deep squat and shoulder mobility tests, and portions of the trunk stability push-up and ASLR tests. Substantial agreement was evident on 8 of the 17 test components. The right and left components of the lunge and the final component of the rotary stability test each demonstrated moderate agreement.

The pair of expert raters varied more in scoring, with excellent agreement on 4 of the 17 test components, including the shoulder mobility test and the final component of the ASLR. Substantial agreement was seen in 9 of the 17 test components. Two components of the lunge and 2 components of the rotary stability tests demonstrated moderate agreement.

When comparing the average scores of the paired novice and expert raters, 14 of the 17 tests demonstrated excellent agreement. Substantial agreement was evident in 1 component of the rotary stability test and 2 components of the in-line lunge.

Funding

University of Evansville Honor’s Program grant and the University of Evansville’s College of Education and Health Science.

My Thoughts

The kappa statistic is actually a good choice in this case because it is fairly conservative and takes into account possible agreement of the raters due to chance.  They also used a weighted kappa which allowed them to rate larger disagreements between the raters less favorably.   However, it should be noted that the categories listed as excellent, substantial, and moderate are pretty aribitrary and are based pretty much on the personal opinions of some other researchers.  Other arbitrary guidelines exist that rate kappa values differently.   I’m not sure how much this really matters in this case, but it is important to note that these ratings aren’t universally accepted.

The most surprising thing to me was that the novice raters tended to have more agreement with each other than the expert raters.  You’d expect that over time your ratings would become more similar than different.  But why did the novice and expert rater’s results tend to agree with each other when they compared them?  My guess is that some of the differences disappeared when they averaged the two novice and two advanced raters before comparing them to each other which could possibly have masked some of the variability.

The authors did suggest that since the tests were only filmed from two angles there was a third dimension missing and this could have influenced the degree of agreement between raters.  Having evaluated people in person, I can definitely see how this could have an impact.  In person you can move around and get a better view of each movement.  Perhaps one reason the expert raters had more disagreement is because they’re more used to looking at movements in three dimensions that novice raters who are less likely to be able to make as much use of this additional information.

All in all, I think the study was fairly well conducted and the results indicate that the scoring of the FMS is relatively reliable.  It did highlight that perhaps work needs to be done to ensure expert raters are scoring similarly.  Another important point to take home is that both sets of raters tended to struggle with agreement on the lunge and rotary stability tests so if you’re using the FMS you might want to pay extra attention when scoring these movements.

I personally would have liked to have seen the same raters score the same subject numerous times to see if the same rater would come up with the same scores each time.  In personal training settings I believe this scenario would be more likely.  Perhaps this could be a route for future investigation.

One final thing I want to mention is that two of the people conducting the study have a personal stake in the outcome since they are involved with the FMS.  This is not to suggest that they would deliberately alter the outcome, but the possibility is always something to be congizant of.  Testing by independent researchers always carries more weight (at least in my mind).

What are your thoughts?

I don’t think you’ll get much argument that the “inner core” is made up primarily of the TVA, multifidi, pelvic floor, and diaphragm.  I would also agree that if the inner core is not working reflexively that you’ll develop a high threshold strategy to stabilize the core resulting in inefficient movement and even pain.  This is why strengthening the TVA and multifidi doesn’t work for eliminating back pain.  It is because reflexive timing and not strength is the issue.

However, what I’m not sure I get is how this test measures the function of the inner core.  Granted, it is certainly a lot harder than I expected (try it if you don’t believe me), and the rolling patterns left my intercostals in pain for a couple days.  But I think that stating that this test can measure the function of the inner core and that it can be corrected by repeating the various rolling patterns might be a little heavy on the speculation.  I’m not sure that there is any EMG to suggest that this might be the case.  You’ll definitely learn a new movement pattern, but whether it is related to inner core function is something I’m not totally sure about. 

Since the chop and lift patterns are often suggested in relation to these exercises, I’d be inclined to think they have something to do with rotation/anti-rotation patterns.  I’m interested to hear what you all think.

Give the test and drills a try and let me know your thoughts.

Hey Mike!  Thanks for taking the time to drop some knowledge bombs on us today.  Obviously I’m already sold on your new product Assess and Correct, but why don’t you give the readers a little rundown on what exactly it is so we know just what we’re talking about here?

Thanks for having me, Mark!

I think Assess and Correct is a powerful tool, as it allows each client to go through over 25 assessments to determine what exactly their specific movement limitations are.

Beyond just telling you what’s tight, weak, stiff, etc., we build off that knowledge with specific corrective exercises to help address those issues!  So if your glutes test weak, we have developed specific exercises to help correct those issues.

And finally, we know and understand that everyone who purchases this product has different levels of dysfunction, so we’ve created progressions to work through instead of just pre-canning one or two exercises.  Quite simply, everyone from the weekend warrior to the elite-level athlete will be able to assess themselves and create a warm-up routine that addresses their specific needs, with an exercise routine that’s specific to their current level of fitness.

It seems that a growing segment of the fitness industry is already using The Functional Movement Screen.  What do you think is the major difference between this and Assess & Correct?

Damn Mark, are you trying to get me in trouble with Gray and Lee?  The last thing I need is a pipe-bomb sitting in my mailbox when I get home someday!

In all seriousness, I have great respect for what Lee and Gray have done with the FMS.  Quite simply, they’ve brought assessment to the forefront of the industry, and you have to applaud them for that.

I think with A&C, our goal has been to not only make the assessment more comprehensive, but more convenient as well.  The beauty of the FMS is its simplicity – seven tests and you’re done. However, you need to find someone with knowledge of the FMS to assess and score you.  

With A&C, there’s a little bit more work involved up front – you have to take static pictures of yourself, along with videotaping yourself perform the various assessments.  However, you can do everything yourself!  Without ever leaving your home, you can determine your specific movement limitations from head-to-toe, along with how to address them.
 

Obviously you don’t want to spend all day assessing people.  Do you think that anyone currently using the movement screen should switch to A&C?  If not, how could they combine the two resources to get the best possible assessment and treatment protocol for themselves or their clients?
 

I think it’s going to be hard to convert people over – many people like the FMS due to its ease of use, along with the fact that you can screen people fairly quickly.

Again, with A&C the biggest difference is it’s going to take more time, but it’s also more comprehensive.  Whether it’s with A&C or a new client at IFAST, I would always like to err on the side of more information, using a more comprehensive testing system, than not.

Could you combine the two products?  Sure.  However, I think on some levels that may be redundant, as we’re looking for a lot of the same issues. 

What do you know about Z-Health and what do you think about their mobility drills vs those in A&C?

I have the utmost respect for Dr. Cobb and his system.  The biggest issue with Z isn’t the system or the drills, but rather the “in-your-face” nature of some of their practitioners.

Even though I think A&C is a fantastic product, I never want to box myself into thinking there’s only one way to do things.  I’m only R-Phase certified in Z, so I can’t speak for the entire system, but I really liken some of the R-Phase drills to micro-mobility.  The goal is to really isolate out each individual joint to promote better movement.  I can definitely see value in this, and I think there’s as much value in the improvements you’d see in motor control/body awareness as there is in the improved mobility.

To summarize, I think A&C would be superior to the end-user in the fact that you have a specific idea of your limitations and what you need to address when it’s all said and done.  Unless you meet with a Z-Health trainer for an assessment, you can’t do this with the current DVD’s and manuals they have available.

I’ve recently heard a lot of people suggesting that the fitness industry has become too much about mobility and activation these days and too little about just getting strong and sexy.  Are we spending too much time on “corrective movements”?  And how do you think mobility work and activation fit into the bigger picture?

I think it all depends on who you’re reading and listening to!

I’ve heard both sides argued lately – some say we’re too caught up in “fixing” things, and others who say we still aren’t good enough at it yet.

I think many of the corrective naysayers are minimalists at heart, and I can understand that to a degree.  However, when you start digging into the research, there’s actual evidence that often it’s not just the strength of a muscle that’s important, but your neuromuscular/motor control.  In other words, who cares if it’s strong if you can’t use it!

This is where that whole mindset goes – I don’t care if you want to lose fat, add muscle, get strong or perform at a high-level.  I want to help you get there, but I also see the big picture.  If I assess you up front and notice specific movement limitations, why would I not address them?

Why would I assume that I can train around them, or somehow magically make them disappear?

This is the “corrective” mindset – to assess limitations and correct them via training.  This could include foam rolling, mobility work, or even the dreaded activation work.  The part you have to focus on, however, is that this is just part of the programming – not all of it.  It’s all pieces to the puzzle.

At the risk of sounding arrogant, Bill and I get some really beat up people at our gym.  Same thing goes for Eric.  I think between the three of us, we have a pretty good idea of what works and what doesn’t.  If foam rolling, mobility, or activation drills didn’t work, we wouldn’t use them.  Period.
 

And finally, a little word association:
 

Squats – Fantastic, when performed and programmed appropriately.  And we use all types: Plate, front, back, safety bar, to a box, free squat, pause squats, full ROM, limited ROM, etc. 
 

Beer – My favorite calorie-laden beverage.  Ever since my Australia trip I’ve been hooked on Heineken, but only because I can’t get my hands on Victoria’s Bitter (VB’s) around here!
 

Crunches – A horrible exercise that not only wrecks backs, but wrecks posture as well.  If your goal is neutral spine and a healthy back, crunches shouldn’t be in your vocabulary, let alone your program.
 

Fat Loss – The “new” hot topic.  Fat loss is always going to be at the fore-front of the fitness industry, but I’m fed-up with fitness marketing.  Fat loss promotions tend to be the worst.
 

Twitter – Not sure on this one.  I can see where some people would really enjoy it, but I guess I’m not that interested in talking about myself all day.  Plus, I’m more of a Facebook whore than a Twitter whore.  What can I say, I’m old-school!
 

That Mark Young clown – A great up-and-coming coach, with a balanced view on training.  I love the fact that you’re willing to read and/or listen to anything, even if it’s out of your comfort zone.  That’s what will make you successful.
 

Thanks Mike for the interview.  Where can people learn more about you or pick up a copy of Assess & Correct?
 

Thanks for having me Mark!  Sorry if I tend to ramble a bit, but your questions got me fired up!

My blog, newsletter, articles and Podcast can all be found at RobertsonTrainingSystems.com.  If you’re interested in picking up a copy of Assess and Correct, check out the Assess and Correct Website.  There you’ll find testimonials from other coaches, more info about the product, as well as video clips directly from the video so you can see how things work.