journal of orthopaedic and sports physical therapy volume 42 issue 6 2012 [doi...

530 | june2012 | volume42 | number6 | journaloforthopaedic&sportsphysicaltherapy

[ research report ]

More than 10 000 Amer-icans seek medical treat-ment for sports, re-creational activity, and

exercise-related injuries on a daily basis.20 Researchers have estimated that 50% to 80% of these injuries are overuse innature and involve the lower extrem-ity.1,11,25 In the military, physical training and exercise-related injuries account for 30% of hospitalizations and 40% to 60% of all outpatient visits, with 10 to 12 inju-ries per 100 soldier-months.12 Although the risk of musculoskeletal conditions and injuries is multifactorial,7,9,10,15,17-19 preliminary evidence suggests that neuro-muscular and strength training programs may be beneficial for preventing the oc-currence of these conditions.7,9,10,15,17-19 However, tools that assess movement to help predict those at highest risk for musculoskeletal conditions and injuries have been lacking for both athletic and military populations. The Functional Movement Screen (FMS) is a relatively new tool that attempts to address mul-tiple movement factors, with the goal of predicting general risk of musculoskeletal

TT STUDY DESIGN: Reliability study.TT OBJECTIVES: To determine intrarater test-

retest and interrater reliability of the Functional Movement Screen (FMS) among novice raters.

TT BACKGROUND: The FMS is used by various examiners to assess movement and predict time-loss injuries in diverse populations (eg, youth to professional athletes, firefighters, military service members) of active participants. Unfortunately, critical analysis of the reliability of the FMS is currently limited to 1 sample of active college-age participants.

TT METHODS: Sixty-four active-duty service members (mean SD age, 25.2 3.8 years; body mass index, 25.1 3.1 kg/m2) without a history of injury were enrolled. Participants completed the 7 component tests of the FMS in a counterbalanced order. Each component test was scored on an ordinal scale (0 to 3 points), resulting in a composite score ranging from 0 to 21 points. Intrarater test-retest reliability was assessed between baseline scores and those obtained with repeated testing performed 48 to 72 hours later. Interrater reliability was based on the assessment from 2 raters, selected from a pool of 8 novice raters, who assessed the same movements on day 2 simultaneously. Descriptive statistics, weighted kappa (w), and percent agreement were calcu-lated on component scores. Intraclass correlation coefficients (ICCs), standard error of the measure-ment, minimal detectable change (MDC95), and associated 95% confidence intervals (CIs) were calculated on composite scores.

TT RESULTS: The average SD score on the FMS was 15.7 0.2 points, with 15.6% (n = 10) of the participants scoring less than or equal to 14 points, the recommended cutoff for predicting time-loss injuries. The intrarater test-retest and interrater reliability of the FMS composite score resulted in an ICC3,1 of 0.76 (95% CI: 0.63, 0.85) and an ICC2,1 of 0.74 (95% CI: 0.60, 0.83), respectively. The stan-dard error of the measurement of the composite test was within 1 point, and the MDC95 values were 2.1 and 2.5 points on the 21-point scale for interra-ter and intrarater reliability, respectively. The inter-rater agreement of the component scores ranged from moderate to excellent (w = 0.45-0.82).

TT CONCLUSION: Among novice raters, the FMS composite score demonstrated moderate to good interrater and intrarater reliability, with accept-able levels of measurement error. The measures of reliability and measurement error were similar for both intrarater reliability that repeated the assessment of the movement patterns over a 48-to-72hour period and interrater reliability that had 2 raters assess the same movement pattern si-multaneously. The interrater agreement of the FMS component scores was good to excellent for the push-up, quadruped, shoulder mobility, straight leg raise, squat, hurdle, and lunge. Only 15.6% (n = 10) of the participants were identified to be at risk for injury based on previously published cutoff values. J Orthop Sports Phys Ther 2012;42(6):530-540, Epub 14 May 2012. doi:10.2519/jospt.2012.3838

TT KEY WORDS: injury prediction, injury preven-tion, injury risk, interrater, intrarater

1Commander, US Army Public Health Command Region-South, Fort Sam Houston, TX. 2Associate Professor, US Army-Baylor University, Fort Sam Houston, TX. 3Physical Therapy Intern, US Army-Baylor University, Fort Sam Houston, TX. 4Assistant Professor, US Army-Baylor University, Fort Sam Houston, TX. 5Researcher, TRUE Research Foundation, San Antonio, TX. 6Director of Musculoskeletal Research, Department of Physical Therapy (MSGS/SGCUY), 81st Medical Group, Keesler Air Force Base, Biloxi, MS. This research study was approved by the Brooke Army Medical Center Institutional Review Board. The views expressed herein are those of the authors and do not reflect the official policy or position of Brooke Army Medical Center, the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Army, Department of the Air Force, Department of Defense, or the US Government. Address correspondence to Dr Deydre S. Teyhen, US Army-Baylor University, 3151 Scott Road, Room 1303 (ATTN: MCCS-HGE-PT), Fort Sam Houston, TX 78234. E-mail: [email protected] or [email protected]

DEYDRE S. TEYHEN, PT, PhD1,2 SCOTT W. SHAFFER, PT, PhD2 CHELSEA L. LORENSON, PT3 JOSHUA P. HALFPAP, PT3

DUSTIN F. DONOFRY, PT3 MICHAEL J. WALKER, PT, DSc4 JESSICA L. DUGAN, PT5 JOHN D. CHILDS, PT, PhD2,6

The Functional Movement Screen: A Reliability Study

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journal of orthopaedic & sports physical therapy | volume 42 | number 6 | june 2012 | 531

conditions and injuries.3-5,13,14,16

The FMS was designed to identify functional movement deficits and asym-metries that may be predictive of general musculoskeletal conditions and injuries, with an ultimate goal of being able to modify the identified movement deficits through individualized exercise prescrip-tion.3,4 The FMS consists of 7 fundamen-tal movement component tests (FIGURE 1) that are scored on a scale of 0 to 3, with the sum creating a composite score rang-ing from 0 to 21 points.3,4 The 7 move-ment patterns that are assessed include the deep squat, in-line lunge, hurdle step, shoulder mobility, active straight leg raise, trunk stability push-up, and quad-ruped rotary stability.

Preliminary research by Kiesel et al14 suggests that National Football League (NFL) players (n = 46) who had a com-posite score less than or equal to 14 on the FMS had an odds ratio of 11.7 (95% confidence interval [CI]: 2.5, 54.5) and a positive likelihood ratio of 5.8 (95% CI: 2.0, 18.4) to sustain a time-loss injury. Al-though the specificity was relatively high (0.9; 95% CI: 0.8, 1.0), the sensitivity was low (0.5; 95% CI: 0.3, 0.7), indicating that FMS composite scores less than or equal to 14 may suggest higher injury risk but FMS composite scores greater than 14 do not rule out future injury risk. In a separate study on a group of Marines, a composite score less than or equal to 14 on the FMS demonstrated limited abil-ity to predict all future musculoskeletal injuries (traumatic or overuse), with a sensitivity of 0.45 and specificity of 0.71, while the same cutoff value was able to predict a serious injury (any injury that was severe enough to remove the par-ticipant from the training program) with a sensitivity of 0.12 and a specificity of 0.94.21 The FMS was also able to predict injury risk in female collegiate athletes.2 Finally, in another study, firefighters with a previous history of injury demonstrated lower FMS composite scores.23 However, it is not clear for which sports or profes-sions the FMS is optimal in predicting injury risk, what types of musculoskel-

etal injuries are predicted by low FMS composite scores, and whether the origi-nal cutoff score of less than or equal to 14 points on the FMS is valid in the different populations.

Additionally, researchers have found that FMS composite scores increased in football players,13 firefighters,6 and service members8 following corrective exercises that addressed possible impair-ments associated with altered movement patterns noted on the FMS component tests. In a group of Marines, 80% of those with a score less than or equal to 14 also demonstrated lower fitness scores on a standardized fitness test compared to those who had an FMS composite score greater than 14.21 However, Okada et al22 found that FMS composite scores were not related to performance or core stabil-ity measures among healthy participants.

Interpretation of FMS scores is lim-ited by the scant evidence16 regarding the FMS's psychometric properties and, in particular, the reliability of both com-posite and individual component scores. An initial study by Minick et al16 found acceptable levels of interrater agreement on the FMS component scores among

novice and expert raters in a sample of active college-age participants (to in-clude college varsity athletes). However, this study had several limitations: (1) it did not assess test-retest reliability, (2) all raters assessed the same movement pattern via videotaped analysis, and (3) it only assessed agreement of individual FMS component scores and did not as-sess the overall FMS composite score, which is typically used as the primary indicator of injury risk. Traditionally, the FMS is assessed in real time, with-out the benefit of video playback. Vari-ability of human movement across trials theoretically should exist; therefore, test-retest analysis could lower the reported agreement values. Additionally, the FMS is often assessed in a group setting (eg, preseason physical or preparticipation screening), requiring the use of multiple raters, who may or may not be the same raters to assess the movement at follow-up testing. Therefore, a more robust reli-ability study is required to enhance the understanding of the psychometric prop-erties of the FMS.

Although these initial FMS studies, which established the validity of the FMS

FIGURE 1. Functional Movement Screen tests. (A) In-line lunge, (B) hurdle step, (C) deep squat, (D) quadruped rotary stability, (E) active straight leg raise, (F) shoulder mobility, and (G) trunk stability push-up.

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[ research report ]for predicting musculoskeletal conditions and injuries and the response to training, are encouraging, their data are prelimi-nary and not published in widely accessi-ble journals. Exploring the psychometric properties of the FMS in a large active population would enhance the general-izability of the previous findings beyond a limited subgroup of professional and collegiate athletes and students. The primary purpose of this study was to de-termine the intrarater (test-retest) and interrater reliability of the FMS com-ponent and composite scores in young, healthy service members, when tested by a counterbalance group of novice raters in real time. Specifically, agreement was assessed on the FMS component scores, whereas reliability, response stability, and error threshold measurements were ob-tained for the FMS composite scores. A secondary purpose of this study was to describe the FMS component and com-posite scores in this population.

METHODS

Participants

Theconveniencesampleincludedparticipants who were recruited over an 8-week period from service

members in training at Fort Sam Hous-ton, TX. Potential participants were provided a briefing about the study and were given the opportunity to volunteer. Participants were eligible for inclusion if they were between the ages of 18 and 35 years or emancipated minors (17-year-olds who are considered adults and al-lowed to join the armed services), fluent in English, and had no current or previ-ous complaint of lower extremity pain, spine pain, or medical or neuromuscu-loskeletal disorders that limited partici-pation in work or exercise in the last 6 months. Participants were excluded if they were currently seeking medical care for lower extremity injuries or had pre-vious medical history that included any surgery for lower extremity injuries. Par-ticipants were also excluded if they were unable to participate in physical training

due to other musculoskeletal injuries; had a history of fracture (stress or trau-matic) in the femur, pelvis, tibia, fibula, talus, or calcaneus; or were known to be pregnant.

Potential participants were provided an overview of the research study and specific details of the entrance criteria. After the presentation was completed, those who met the entrance criteria were asked to squat and then hop unilaterally on each leg in the group setting. Individ-uals who met the entrance criteria and did not have pain on the squat and hop tests were informed about upcoming data collection dates. Those individuals who opted to volunteer returned the follow-ing week to sign informed consent forms and were enrolled in the study. Within the military training environment, these procedures allowed potential partici-pants the option to not return if they were not interested in volunteering in the study, and were designed to minimize any

potential perception of coercion. All par-ticipants signed consent forms approved by the Brooke Army Medical Center In-stitutional Review Board.

ExaminersThe novice examiners participating in this study consisted of 8 physical therapy students enrolled in their second and third semesters of a doctor of physical therapy training program prior to their 1-year clinical internship. Before testing, all examiners underwent 20 hours of FMS training led by 4 physical therapists and 1 research assistant. Four physical therapy students were randomly as-signed to the participants to assess intra-rater test-retest reliability by assessing the FMS on day 1 and day 2. The goal of randomly selecting a rater to perform the intrarater test-retest reliability was to increase the variability in the study design. Each rater used for the intrarater test-retest reliability measured between

TABLE 1 Demographics

Abbreviation: CI, confidence interval.

Type Mean SD 95% CI

Age, y 25.2 3.8 24.3, 26.2

Height, cm 175.5 9.6 173.1, 177.9

Weight, kg 77.5 12.5 74.4, 80.7

Body mass index, kg/m2 25.1 3.1 24.3, 25.9

TABLE 2 FMSDescriptiveAnalysis*

Abbreviation: FMS, Functional Movement Screen.*The data displayed represent the first analysis of rater 1 on the first day of data collection (n = 64).

FMS Component Score

Test 0 1 2 3 Mean SD

Trunk stability push-up 0 7 29 27 2.3 0.7

Quadruped rotary stability 0 3 56 5 2.0 0.3

Shoulder mobility 0 2 19 43 2.6 0.6

Active straight leg raise 0 1 36 27 2.4 0.5

Deep squat 0 3 42 19 2.3 0.5

Hurdle step 0 1 51 12 2.2 0.4

In-line lunge 0 1 29 33 2.5 0.5

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14 and 18 participants. There were no differences in outcomes across raters, so aggregate data were analyzed.

A second set of 4 physical therapy stu-dents were randomly assigned to view the participants movement simultaneously with the first set of raters for the inter-rater reliability assessment on day 2. To minimize bias, raters were randomly as-signed, raters for day 2 were blinded to day 1 raters measurements, pairs of rat-ers on day 2 were blinded to each other's analysis and scoring, and 48 to 72 hours of time elapsed between intrarater test-retest reliability measurements. The goal of having a random set of 2 raters assess each participant was to increase the vari-ability in the study design to more closely mimic field conditions, which often in-clude mass screenings that utilize mul-tiple raters.

ProceduresThe FMS is composed of 7 component tests used to assess different fundamental movement patterns.3-5 Participants com-pleted the component tests in a coun-terbalanced order, including the deep squat, hurdle step, in-line lunge, shoulder mobility, active straight leg raise, trunk stability push-up, and quadruped rotary stability tests (FIGURE 1). Five of 7 compo-nent tests assess asymmetry by measuring the test bilaterally. If discrepancies exist between the left and right sides, asymme-try is noted for that component test and the lower of the 2 scores is included in the FMS composite score. In addition to the 7 component tests, the FMS includes 3 clearing tests that assess for pain: shoul-der internal rotation and abduction with the hand placed on the opposite shoulder, lumbar extension performed in the prone press-up position, and end-range lumbar flexion in quadruped. Pain on a clearing test resulted in a score of 0 for the shoul-der mobility, trunk stability push-up, or rotary stability test, respectively. Partici-pants performed all tests without a pre-participation warm-up.

Each component test was scored on an ordinal scale (0 to 3 points), based

on the quality of movement, with 3 be-ing the maximum score.3-5 A score of 2 indicated that the participant required some type of compensation or was un-able to complete the entire movement. A score of 1 was given if the individual was unable to remain in the movement posi-tion throughout the movement, lost bal-ance during the test, or did not meet the minimum criteria to score a 2. Pain dur-ing any of the FMS component tests or during any of the clearing tests indicated a score of 0. All participants were allowed to perform each component test up to 3 times, and the maximal score achieved was recorded. The scores of the compo-nent tests were summed, resulting in a composite score from 0 to 21 points, with 21 being the maximum composite score. Additional details on scoring of each of the component tests and the composite score are provided elsewhere3-5 and in the APPENDIX.

Statistical AnalysisDescriptive statistics and frequency counts were calculated. Agreement of the component tests was analyzed with a weighted kappa statistic. The weighted kappa scores were as follows: 80% and higher, excellent agreement; from 60% to 79.9%, substantial levels of agreement; from 40% to 59.9%, moderate agree-ment; and below 40%, poor to fair agree-ment.24 Reliability of the composite test scores was analyzed using intraclass cor-relation coefficients (ICCs). ICC values of 0.75 and above represent good reliability, those between 0.50 and 0.74 represent moderate reliability, and those below 0.50 indicate poor reliability.24 Intrarater test-retest reliability was assessed using an ICC3,1 model, while interrater reliabil-ity was assessed using an ICC2,1 model. Response stability of the intrarater and interrater reliability of the composite scores was calculated using the standard error of the measurement (SEM) at the 95% level of confidence. The minimal detectable change (MDC95) values at the 95% level of confidence were calculated to determine error thresholds. Statistical

analyses were conducted using SPSS Ver-sion 17.0 (SPSS Inc, Chicago, IL).

RESULTS

Sixty-four participants (53 males, 11 females) met the inclusion and exclusion criteria and complet-

ed the study (TABLE 1). The mean SD age of the participants was 25.2 3.8 years and their body mass index was 25.1 3.1 kg/m2. Overall, the participants in-cluded routine exercisers who endorsed a statement that they exercised a mini-mum of 4 days per week (n = 54, 78.2%). Although the participants were attending training for their military occupation, the majority of the participants were routine exercisers for more than 3 years. Specifi-cally, 29 (45.3%) participants reported performing routine exercise for more than 5 years, 21 (32.8%) for 3 to 5 years, 9 (14.1%) for 1 to 3 years, and 5 (7.8%) for less than 1 year. Descriptive statistics on FMS performance are provided in TABLE 2. None of the participants had pain on the 3 FMS clearing tests. Interrater reliability was calculated on 63 participants, based on an illness of 1 of the raters on day 2 of testing. Only 15.6% (n = 10) of the par-ticipants were identified to be at risk for injury, based on an FMS composite score of less than or equal to 14 points.

Agreement of the 7 component tests of the FMS (scored 0 to 3) demonstrated moderate to excellent interrater agree-ment (TABLE 3). Specifically, the novice raters demonstrated excellent interrater agreement on the trunk stability push-up; substantial interrater agreement on the quadruped rotary stability, deep squat, active straight leg raise, hurdle step, and shoulder mobility component tests; and moderate interrater agreement on the in-line lunge. Intrarater (test-re-test) agreement scores at 48 to 72 hours demonstrated substantial agreement on the trunk stability push-up, shoulder mo-bility, active straight leg raise, deep squat, and in-line lunge component tests; mod-erate agreement on the hurdle step; and poor agreement on the quadruped rotary

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[ research report ]

stability component test.The interrater reliability (same day)

of the FMS composite score (scored 0-21) resulted in an ICC2,1 of 0.76 (95% CI: 0.63, 0.85) and was considered good (TABLE 4). The SEM for interrater reliabil-ity of the composite test was 0.92 points, and the MDC95 was 2.54 points on the 21-point scale. Visual representation of the FMS composite scores between rat-ers is provided in FIGURE 2. The intrarater reliability (test-retest at 48 to 72 hours) of the FMS composite scores resulted in an ICC3,1 of 0.74 (95% CI: 0.60, 0.83) and was considered to be moderate (TABLE 4). Visual representation of the intrarater test-retest FMS composite scores is pro-vided in FIGURE 3. The SEM for intrarater

test-retest reliability was 0.98 points and the MDC95 was 2.07 points.

DISCUSSION

TheFMShasanadequatelevelofreliability when assessed in healthy service members by novice raters.

The interrater agreement of the FMS component scores ranged from moder-ate to excellent, with 6 of the 7 tests cat-egorized as having substantial agreement (w60%). The intrarater and interrater point estimates of the FMS composite score reliability ranged from 0.74 to 0.76, with the 95% CIs suggestive of moderate to good reliability. The SEMs for both interrater and intrarater reliability were

less than 1 point, while the MDC95 ranged from 2.1 to 2.5 points on the 21-point scale. The SEM and MDC values were similar for both intrarater reliability that repeated the assessment of the movement patterns over a 48-to-72hour period and interrater reliability that had 2 raters as-sess the same movement pattern simul-taneously. Therefore, one can expect the error of measurement to be within 1 point across raters and across time, while a minimum improvement between 2 and 3 points on the 21-point scale would be required to demonstrate a real change over time.

These results are consistent with a prior publication on FMS reliability. Minick et al16 reported substantial to ex-cellent interrater agreement on individ-ual FMS component scores when using 2 novice and 2 expert raters assessing videotape performance of active college-age students and varsity athletes. Add-ing to the literature, our study provides detailed information on the intrarater and interrater reliability of both FMS component and composite scores by randomly assigned novice raters. Spe-cifically, our study utilized 8 entry-level physical therapy students as raters to collect data prior to their clinical intern-ship. Additionally, these raters measured all movements in real time, without the benefit of being able to replay a video-tape (the methodology used by Minick et al16). The increased number of raters and real-time analysis of movement in mul-tiple participants in our study mimic a preparticipation screening environment, thus enhance the generalizability of the results. Further research is needed to as-sess the stability of the FMS scores over longer periods. Ultimately, the reliability of this group of novice raters was com-parable to previously published research and provides further support for the FMS as a reliable tool to screen in a relatively diverse, noncollegiate but physically ac-tive population.16

Only 15.6% (n = 10) of the partici-pants in this study had an FMS compos-ite score less than or equal to 14 points.

TABLE 3AgreementofFMSComponent

Scores(0-3points)

Abbreviations: CI, confidence interval; FMS, Functional Movement Screen.

Type/Test Percent Agreement w 95% CI

Interrater

Trunk stability push-up 78 0.82 0.73, 0.90

Quadruped rotary stability 92 0.77 0.57, 0.96

Shoulder mobility 86 0.73 0.57, 0.89

Active straight leg raise 84 0.69 0.51, 0.87

Deep squat 83 0.68 0.51, 0.85

Hurdle step 88 0.67 0.45, 0.88

In-line lunge 68 0.45 0.25, 0.65

Intrarater

Trunk stability push-up 68 0.68 0.55, 0.81

Quadruped rotary stability 83 0.29 0.05, 0.50

Shoulder mobility 81 0.68 0.53, 0.80

Active straight leg raise 80 0.60 0.42, 0.74

Deep squat 88 0.76 0.63, 0.85

Hurdle step 86 0.59 0.42, 0.73

In-line lunge 83 0.69 0.48, 0.77

TABLE 4ReliabilityofFMSComposite

Scores(0-21points)

Abbreviations: CI, confidence interval; FMS, Functional Movement Screen; ICC, intraclass correlation coefficient; MDC95, minimal detectable change at the 95% level of confidence; SEM, standard error of measurement.

Type ICC 95% CI SEM MDC95Interrater 0.76 0.63, 0.85 0.92 2.54

Intrarater (test-retest) 0.74 0.60, 0.83 0.98 2.07

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Although this may not seem surprising, given that the participants were relative-ly healthy, it supports the suggestion by Cook et al3,4 that FMS scores can identify altered movement patterns in generally healthy and pain-free participants. Our results are similar to those published by OConnor et al,21 who found that 10% of the 874 Marine officer candidates scored less than or equal to 14 points on the FMS. If the initial research that identified the cutoff value were validated, it would suggest that the FMS would be capable of identifying a subset of individuals at increased risk for time-loss injury within a population of young, healthy service members. Based on the use of the FMS for mass screenings (eg, preseason or an-nual physical examinations), an injury prediction screening that could identify only 15.6% of the population as having a high injury risk would allow the asso-ciated medical staff to prioritize the al-location of limited resources toward the development of individualized injury prevention interventions (eg, corrective exercise prescriptions) for this group. However, the validity of the 14-point cut-off score for this sample cannot be verified in this study, because longitudinal follow-up was not performed to assess actual in-jury rates. Based on the SEM of 1 point and the MDC95 value between 2.1 and 2.5 points, it would be more conservative to use a cutoff score of 15 (based on SEM) or 16 to 17 (based on MDC95) to determine those who may benefit from corrective exercise prescription to help mitigate in-jury risk, until the validity of the 14-point cutoff value can be determined.

One of the limitations noted in the FMS component tests was a restriction in the range of scores. Specifically, based on our inclusion/exclusion criteria, no participants scored a 0 on any of the FMS component tests, and only 18 of the 446 scored movement patterns resulted in a score of 1; the remaining movement patterns either received a score of 2 or 3. This restriction in range might have reduced the reliability estimates of the FMS component scores. For example,

the in-line lunge was determined to have a weighted kappa of 0.45; for this test, no movements were scored as a 0 or 1. Ad-ditionally, only 11 of the 63 paired ratings had a disagreement, with 25 agreements for a score of 2 and 27 agreements for a

score of 3. Compared to the other FMS component scores, the in-line lunge and the quadruped rotary stability had the biggest discrepancy between the percent agreement (68% and 83%, respectively) and weighted kappa (0.45 and 0.29, re-

Rate

r 2

Rater 1

12 13 14 15 16 17 18 19 Total

12 2 1 1 0 0 0 0 0 4

13 1 0 1 0 0 0 0 0 2

14 1 2 1 0 0 0 0 0 4

15 0 0 3 4 3 0 0 0 10

16 0 1 4 1 6 1 0 0 13

17 0 0 1 3 3 2 3 2 14

18 0 0 0 1 1 6 4 0 12

19 0 0 0 0 0 1 1 1 3

20 0 0 0 0 0 0 0 1 1

Total 4 4 11 9 13 10 8 4 63

FIGURE 2. Comparison of Functional Movement Screen composite scores between rater 1 and rater 2. Green boxes indicate agreement (n = 20), yellow boxes indicate a composite-score difference of only 1 point (n = 27), and orange boxes indicate a composite-score difference of 2 to 3 points (n = 16).

FMS

Day

1 Co

mpo

site

Sco

re

FMS Day 2 Composite Score

12 13 14 15 16 17 18 19 Total

10 1 0 0 0 0 0 0 0 1

11 0 0 0 0 0 0 0 0 0

12 1 1 1 0 0 0 0 0 3

13 2 1 1 1 0 0 0 0 5

14 0 1 1 1 2 1 0 0 6

15 0 1 2 5 3 1 0 0 12

16 0 0 5 0 4 3 1 0 13

17 0 0 0 2 4 1 2 0 9

18 0 0 1 0 1 2 4 4 12

19 0 0 0 0 0 2 0 0 2

20 0 0 0 0 0 0 1 0 1

Total 4 4 11 9 14 10 8 4 64

FIGURE 3. Comparison of FMS composite scores for rater 1 (day 1 to day 2). Green boxes indicate agreement (n = 17), yellow boxes indicate a composite-score difference of only 1 point (n = 26), orange boxes indicate a composite-score difference of 2 to 3 points (n = 20), and the red box indicates a composite-score difference greater than 3 points (n = 1). Abbreviation: FMS, Functional Movement Screen.

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[ research report ]

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13. Kiesel K, Plisky P, Butler R. Functional move-

spectively). Interestingly, the lowest levels of agreement between novice raters for both our study and Minick et al16 involved the in-line lunge and quadruped rotary stability tests. Difficulty in performing the quadruped rotary stability test (only 5 of the 64 participants obtained a score of 3 on day 1) also limited variability and potentially intrarater agreement of this measure. Although the restricted range might have influenced statistical calcula-tions, it is important to point out that rat-er experience and lack of clearly defined scoring criteria, especially mid-range performance, may have also influenced results for these select measures. Future research should determine whether bet-ter criteria may help to differentiate levels of performance on the quadruped rotary stability test or to determine the influ-ence of removing the quadruped rotary stability test on the predictive validity of the FMS composite score.

Future study designs should assess the reliability of the FMS using novice raters and participants with varying activity levels and sport-specific requirements. Additional longitudinal studies are also required to establish the predictive va-lidity and optimal cut score for various populations. This level of critical investi-gation would help to enhance the external validity of the FMS and to substantiate its use in the general clinical population, as well as in specific sports settings. Future research should also determine whether there is a ceiling effect in the ability of the FMS to detect change over time. Based on the MDC95 of 2.1 to 2.5 points, posi-tive change may not be able to be noted for individuals who score greater than 18 points at baseline testing. Different scoring criteria or cutoff values may be needed to better differentiate high-end performance on the FMS.

CONCLUSIONS

Among novice raters, the FMScomposite score demonstrated moderate to good interrater and

intrarater reliability, and acceptable lev-

els of measurement error. The measures of reliability and measurement error were similar for both intrarater reliability that repeated the assessment of the move-ment patterns over a 48-to-72hour pe-riod and interrater reliability that had 2 raters assess the same movement pattern simultaneously. The interrater agreement of the FMS component scores was good to excellent for the push-up, quadru-ped, shoulder mobility, straight leg raise, squat, hurdle, and lunge. Only 15.6% (n = 10) of the participants were identified as being at risk for injury based on previ-ously published cutoff values. t

KEYPOINTSFINDINGS: When using novice raters, the FMS composite scores had moderate to good reliability (ICC = 0.74 and 0.76; SEM, 1.0 points; MDC95, 2.1 and 2.5 points) and the FMS component scores ranged from moderate to excellent agreement (w = 0.29-0.82).IMPLICATIONS: The FMS has adequate re-liability when assessed in young, healthy service members by novice raters over a 48-to-72hour period.CAUTION: Reliability data must be inter-preted within the context of the sample tested and the methods used (ie, time between testing for test-retest reliability estimates).

ACKNOWLEDGEMENTS: This study was done in collaboration with research assistants from the University of Texas Health Science Center, Physical Therapy Department, San Antonio, TX: Mark Bauernfeind, Francis Bisagni, Jor-dan Boldt, Cindy Boyer, Cara Dobbertin, Steve Elliot, Angela Gass, Germaine Herman, Lacey Jung, Jake Mitchess, Teddy Ortiz, Kelly Rabon, Jason Smith, Megan Swint, Joshua Trock, and Jerry Yeung. Additional research assistants from US Army-Baylor University, Depart-ment of Physical Therapy, US Army Medical Department Center and School, San Anto-nio, TX: First Lieutenant Moshe Greenberg, Captain Sarah Hill, First Lieutenant Crys-tal Straseske, First Lieutenant Sarah Villena, First Lieutenant Christina Yost, First Lieu-tenant Kristen Zosel, First Lieutenant Rick

Warren, and First Lieutenant Sam Wood. Illustrations for the APPENDIX were provided by Elizabeth Holder.

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MORE INFORMATIONWWW.JOSPT.ORG@

ment test scores improve following a stan-dardized off-season intervention program in professional football players. Scand J Med Sci Sports. 2011;21:287-292. http://dx.doi.org/10.1111/j.1600-0838.2009.01038.x

14. Kiesel K, Plisky PJ, Voight ML. Can serious injury in professional football be predicted by a preseason functional movement screen? N Am J Sports Phys Ther. 2007;2:147-158.

15. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and proprioceptive training program in prevent-ing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. 2005;33:1003-1010. http://dx.doi.org/10.1177/0363546504272261

16. Minick KI, Kiesel KB, Burton L, Taylor A, Plisky P, Butler RJ. Interrater reliability of the func-tional movement screen. J Strength Cond Res. 2010;24:479-486. http://dx.doi.org/10.1519/JSC.0b013e3181c09c04

17. Myer GD, Ford KR, Brent JL, Hewett TE. The effects of plyometric vs. dynamic stabilization

and balance training on power, balance, and landing force in female athletes. J Strength Cond Res. 2006;20:345-353. http://dx.doi.org/10.1519/R-17955.1

18. Myer GD, Ford KR, McLean SG, Hewett TE. The effects of plyometric versus dynamic stabiliza-tion and balance training on lower extremity bio-mechanics. Am J Sports Med. 2006;34:445-455. http://dx.doi.org/10.1177/0363546505281241

19. Myer GD, Ford KR, Palumbo JP, Hewett TE. Neuromuscular training improves performance and lower-extremity biomechanics in female athletes. J Strength Cond Res. 2005;19:51-60. http://dx.doi.org/10.1519/13643.1

20. National Center for Injury Prevention and Con-trol, Centers for Disease Control and Prevention. CDC Injury Research Agenda. Atlanta, GA: US Department of Health and Human Services; 2002.

21. OConnor FG, Deuster PA, Davis J, Pappas CG, Knapik JJ. Functional movement screening: predicting injuries in officer candidates. Med Sci Sports Exerc. 2011;43:2224-2230. http://dx.doi.

org/10.1249/MSS.0b013e318223522d 22. Okada T, Huxel KC, Nesser TW. Relationship

between core stability, functional movement, and performance. J Strength Cond Res. 2011;25:252-261. http://dx.doi.org/10.1519/JSC.0b013e3181b22b3e

23. Peate WF, Bates G, Lunda K, Francis S, Bellamy K. Core strength: a new model for injury prediction and prevention. J Oc-cup Med Toxicol. 2007;2:3. http://dx.doi.org/10.1186/1745-6673-2-3

24. Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. 2nd ed. Up-per Saddle River, NJ: Prentice Hall; 2000.

25. van Mechelen W. Running injuries. A review of the epidemiological literature. Sports Med. 1992;14:320-335.

FUNCTIONAL MOVEMENT SCREENScore Criteria Illustration

Deep Squat

3 Upper torso is parallel with tibia or toward vertical Femur below horizontal Knees are aligned over feet Dowel aligned over feet

2 Performed with heels on 2 6-in board Upper torso is parallel with tibia or toward vertical Femur below horizontal Knees are aligned over feet Dowel aligned over feet

1 Performed with heels on 2 6-in board If any of the 4 criteria are not met when the squat is performed with

heels on 2 6-in board, the score is 1

0 Pain during test

APPENDIX

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[ research report ]

Score Criteria Illustration

Hurdle Step (test both right and left sides)*

3 Foot clears cord (does not touch) and remains dorsiflexed as leg is lifted over hurdle

Hips, knees, and ankles remain aligned in the sagittal plane Minimal to no movement is noted in lumbar spine Dowel and hurdle remain parallel

2 Alignment is lost between hips, knees, and ankles Movement is noted in lumbar spine Dowel and hurdle do not remain parallel

1 Contact between foot and hurdle Loss of balance is noted

0 Pain during test

In-line Lunge (test both right and left sides)*

3 Knee touches board behind heel Dowel and feet remain in sagittal plane Dowel contacts remain (head, thoracic spine, sacrum) Dowel remains vertical, no torso movement noted

2 Knee does not touch behind heel Dowel and feet do not remain in sagittal plane Dowel contacts do not remain Dowel remains vertical Movement is noted in torso

1 Loss of balance is noted Inability to achieve start position Inability to touch knee to board

0 Pain during test

Active Straight Leg Raise (test both right and left sides)*

3 Malleolus of tested lower extremity located in the region between mid-thigh and anterior superior iliac spine of opposite lower extrem-ity (green region)

Opposite hip remains neutral (hip does not externally rotate), toes remain pointing up

Opposite knee remains in contact with board

2 Malleolus of tested lower extremity located in the region between mid-thigh and knee joint line of opposite lower extremity (yellow region) while other criteria are met

1 Malleolus of tested lower extremity located in the region below knee joint line of opposite lower extremity (red region) while other criteria are met

0 Pain during test

APPENDIX

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Shoulder Mobility (test both right and left sides)*

3 Fists are within 1 hand length

2 Fists are within 1.5 hand lengths

1 Fists are not within 1.5 hand lengths

0 Pain during testShoulder mobility clearing test: if pain is noted as elbow is lifted,

shoulder mobility is scored as 0

Trunk Stability Push-up

3 Perform 1 repetition; the thumbs are aligned with forehead for males and chin for females

Body is lifted as 1 unit (no sag in lumbar spine)

2 Perform 1 repetition; the thumbs are aligned with chin for males and clavicle for females

Body is lifted as 1 unit (no sag in lumbar spine)

1 Unable to perform 1 repetition with thumbs aligned with chin for males and clavicle for females

0 Pain during testExtension clearing test: if pain is noted during a prone press-up, push-

up is scored as 0

APPENDIX

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[ research report ]


Quadruped Rotary Stability (test both right and left sides)*

3 1 unilateral repetition (lift arm and leg from same side of body) Keep spine parallel to board Knee and elbow touch in line over the board and then return to the

start position

2 1 diagonal repetition (lift arm and leg from opposite sides of body) Keep spine parallel to board Knee and elbow touch in line over the board and then return to the

start position

1 Inability to perform diagonal repetition

0 Pain during testFlexion clearing test: if pain is noted during quadruped flexion, rotary

stability is scored as 0

*For component tests that are scored for both the right and left sides, the lower score is used when calculating the Functional Movement Screen composite score.

APPENDIX

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journal of orthopaedic and sports physical therapy volume 42 issue 6 2012 [doi...

Documents

fms composite score

interrater reliability

composite test

functional movement

timeloss injuries

military populations

component scores

sd age