1. Kathleen Lautzenheiser, SPT Virginia Commonwealth University Functional Movement Screen (FMS)

2. Objectives Define FMS Patient population Components of the FMS Exercises to improve dysfunctional movement patterns Evidence to sport populations and validity of the screen

3. What is the Functional Movement Screen? The FMS philosophy started by Gray Cook- orthopedic PT and strength and conditioning specialist FMS- A set of movement tests that screen for quality movement patterns as well as asymmetrical movement patterns SFMA- Selective functional movement assessment- used on those with known pain For some people, asymmetries between the L and R sides exist at very basic levels of movement. Over time, these limitations may lead to compensations, inefficient movement patterns, and potential injury. 2

4. The idea of the FMS is to find the “weak link” in a movement pattern and improve it through therapeutic exercise 2 By addressing the limitations, the athlete will be more efficient, improve performance, and will decrease risk for injury These imbalances and asymmetrical movement patterns should be addressed prior to training and competition

5. Performance Pyramid “Mental image” of human movement Building of one movement type on another First level- Functional Movement- the foundation, represents mobility and stability Second level- Functional Performance- general power or gross athleticism; the efficiency of movement (ex. test vertical leap) Third level- Functional Skill- the ability to participate in a specific sport or play a specific position within that sport Cook, 2003

6. Optimum Performance Pyramid Large foundation- full range of movement Body control and awareness in a variety of positions Movement efficiency and sport skill are balanced Movement patterns without compensations Cook, 2003

7. Overpowered Performance Pyramid Poor score on mobility and stability tests, high on power production, adequate in skill Free movement limited by poor flexibility or poor stability Need to focus on the foundation work in order to see greater improvement in sport/skill AND prevent injury Yoga, massage, ROM over weights Cook, 2003

8. Underpowered Performance Pyramid Excellent freedom of movement, but with poor efficiency and power The training for this type of athlete should focus on efficiency and power without negatively affecting movement patterns Ex. plyometrics, power training, weight training with free weights; work on sport- specific skills as power, speed, and agility improve Cook, 2003

9. Underskilled Performance Pyramid Appropriate functional movement patterns and good power production but poor sport skill These athletes would benefit from technique training to refine or improve mechanics Maybe need to address anxiety, psychological factors Cook, 2003

10. Mobility and Stability Mobility- combination of muscle flexibility and joint ROM Stability- ligamentous integrity- static and dynamic (ex. SLS vs. abdominal stabilization during sport) Athletes will always sacrifice the quality of motion for the quantity of motion, and in turn develop compensatory movement patterns in order to overcome their movement deficits 2

11. FMS Scoring The screen is comprised of seven fundamental movement patterns that require both mobility and stability 2 Scoring (0-3) 3- perfect completion 2- completion with compensation 1- inability to complete 0- pain with the movement pattern Total composite score out of 21; if the R and L sides are tested, take the lowest score to count towards the composite score Score all patterns prior to coming up with a conclusion on functional deficits

12. First evaluate painful tests, then R or L asymmetries If asymmetries are present, address the pattern and perform exercises and skills to strengthen or correct that pattern If the same score for all patterns (ex. score of 2), use best judgment where to begin depending on the requirement of the sport (ex. hurdles for a hurdler) Further testing with goniometers and special tests to determine the weak links

13. Movement Pattern: Deep Squat Deep squat- hip, knee, ankle mobility and stability; dowel overhead assesses flex and ABD of the shoulders extension of the thoracic spine Form-dowel overhead, squat down while holding the dowel with extended elbows OH; passing is heels flat, feet parallel, hips below knees, knees over feet, arms must stay overhead

14. Exercises: Deep Squat Corrective exercises: 1. Prone Quad stretch 2. Standing rectus stretch 3. Kneeling dorsiflexion 4. Squat progression with heel lift (1-2”) and heel platform (2-6”), decreasing the size of the heel lift/platform as able until performing on floor (Ex. deep squat with rotation, Y squat) Patient population- swimmers, volleyball, rowers, etc.

15. Squat Progression Deep Squat, arm raise to ceiling Y squat, arms extended overhead

16. Movement Pattern: Hurdle Step Hurdle step- test of hip, knee, and ankle mobility and stance leg stability The hurdle step is designed to challenge the body’s proper stride mechanics during a stepping motion. Form- hurdle set to height of tibial tuberosity; step over hurdle, touching heel to floor and return to the start; must have the hip, knee, and ankle aligned forward, the dowel cannot tip L or R, and the spine has little movement

17. Exercises: Hurdle Step Corrective exercises: 1. Stride stretch (with hip ER, spinal rotation), 2. Standing hip-hug stretch (across front of body, then outside body) 3. Mountain climber with flex/ext of hip 4. Lunge stretch on board  plank position  spinal extension Patient population- runners, cyclists, climbers, jumpers

18. Standing hip hug stretch Lunge-plank-spinal extension

19. Movement Pattern: In-line Lunge In-line lunge- to assess hip and ankle mobility and stability, quad flexibility, and knee stability Form- The feet should face forward and the foot on the ground; passing is minimal upper body movement, feet on tape, back knee touching back of front heel, no tipping R or L Places the body in a position that challenges the body’s trunk and extremities to resist rotation and maintain proper alignment.

20. Exercises: Lunge Corrective exercises: 1. Lunge stride and twist progression, 2. Half kneel dowel twist 3. Lock-leg bridge (one knee to chest, SL bridge) Patient population- field and court athletes, athletes that perform quick direction changes

21. Lunge stride and twist progression Half kneel dowel twist

22. Shoulder Mobility Shoulder mobility- requires scapular and thoracic spine mobility; pt may have tight pecs or lats or ST dysfunction Form- first measure distance from the wrist to the tip of third finger; make a fist with each hand with thumb in fist and max ext, IR, and ADD on one shoulder and max flex, ER, and ABD with the other-- measure the distance apart

23. Exercises: Shoulder Mobility Corrective exercises: 1. Open up anterior chest wall-stretch pecs, lats; 2. Wall sit (both hips ER) with arm raise (keeping back of hands against wall), 3. Foam roller “snow angles” 4. S/L “torso twist” with shoulder ROM Patient population- throwing athletes

24. S/L torso twist with shoulder ROM

25. Active Straight Leg Raise Active straight leg raise- to assess active hamstring flexibility, movement of opposite hip (limitation due to an anterior tilted pelvis) AND also core stability Form- in doorway, pelvis in the center of the doorway, raise one leg while keeping the other flat on the ground

26. Corrective exercises: 1. Leg-lowering progression (keeping spine elongated, scissor movement), may use support against a wall 2. Single leg bridge- hips up, extend leg, perform SLR 3. Dip bridge An open chain movement- requires core training for stability Leg lowering progression- wall

27. Dip bridge Single leg bridge

28. Trunk Stability Push Up Trunk stability push-up- requires trunk stability in sagittal plane during UE movement Form- prone- feet together, hands shoulder width apart, thumbs in line with forehead (male) or chin (female) or clavicle (if cannot perform); pt performs one push up; there should be no lag in the lumbar spine

29. Exercises: Trunk Stability Corrective exercises: 1. Incline push up 2. Push up walk out 3. Push up with leg curl 4. Push up with hand clap as able Patient population- basketball, volleyball, football, where blocking is common and forces are transferred from the trunk stabilizers to the extremities

30. Rotary Stability Rotary stability- assesses multi-plane trunk stability during a combined UE and LE motion- requires NM coordination and transfer of energy through the torso from one body segment to the other Form- quadruped- knees 90 and ankles in DF- board between hands and knees so they are in contact with the board; touch one knee to the same elbow Looking to have a neutral spine, straight arms and legs that stay along the length of the board; do alternate arm and leg if cannot perform

31. Exercises: Rotary Stability Corrective exercises: 1. Leg fall out (knees bent or straight) 2. Bird dog 3. Rolling (initiate with arm or leg) 4. Chops/lifts Patient population- running, sprinting, explosive movements

32. Rolling example Leg fall out

33. Application to PT Patient Population Patients are already coming to us injured but we can help them safely return to sport Consider those with chronic, repetitive injuries through work or sport- why do they keep getting injured? Is there a neuromuscular component? Flexibility/stability component? Return to sport? FMS may not predict injury BUT compensations will occur in order to participate in the sport Consider the goals of the patient, activity level

34. “Association Between the Functional Movement Screen and Injury Development in College Athletes” International Journal of Sports Physical Therapy 2015 Prospective cohort, 168 athletes, DI- swimming/diving, rugby, female soccer players All athletes received a composite score and individual scores Injuries recorded must be due to athletic participation, limit training for 24 hours and require medical attention Results- FMS score for injured was 13.6 while the uninjured score was 15.5 Athletes with an FMS composite score ≤14 combined with a self-reported past history of injury were at 15 times increased risk of injury.

35. “Prediction of Injury by Limited and Asymmetrical Fundamental Movement Patterns in American Football Players” Journal of Sport Rehabilitation, 2014 Authors speculated that asymmetries in basic body weight tasks would also present in more complex movements Purpose- 1. to determine whether asymmetrical movement patterns R vs. L have a relationship with injury during preseason and 2. to validate the cutoff score of 14 The composite score and any asymmetries were collected from two professional football teams over the course of two years, 238 players total

36. Results: 25% became injured over the course of the preseason- most common were knee and hamstring injuries The mean FMS score for those injured and uninjured was 16 and 17.4 Relative risk for injury= 1.87 for those with a score ≤ 14; 1.80 for those with an asymmetry Conclusion: having at least 1 asymmetry increases risk for injury, regardless of composite score AND a score of ≤14 is valid in predicting time lost due to injury

37. Composite vs. Individual Cut Off Scores Cohort study- Mokha et al. 2016 84 rowers, volleyball players, soccer players, DII athletes Purpose- to determine if an asymmetry or score of 1 on an individual FMS test or a composite score ≤14 predicts MSI in collegiate athletes Preseason administration- tracked injury throughout the season (MSI- required medical help and altered training) Composite scores were low (≤14) or high (>14) Results- Athletes with FMS scores of ≤14 were not more likely to sustain an injury than those with higher scores (RR= 0.68). However, athletes with an asymmetry or individual score of 1 were 2.73 times more likely to sustain an injury (RR= 2.73)

38. “Reliability, Validity and Injury Predictive Value of the Functional Movement Screen” American Journal of Sports Medicine 2016 Systematic review- search in the MEDLINE and ScienceDirect databases Purpose: to determine whether or not the FMS is a reliable and valid screening tool to identify functional asymmetries and what specific score correlates with higher risk for injury Inclusion criteria- English language studies, use of the screen to assess uninjured people prior sport participation Exclusion criteria- any reviews, case reports, or abstracts

39. Results/Discussion Reliability: “The FMS as a composite score has excellent interrater and intrarater reliability and can be effectively administered by raters of varying experience with the FMS, with and without certification” Injury Predictive Value: “A pooled quantitative synthesis using 9 studies was performed using a cutoff score of ≤14; An OR of 2.74 was found, indicating that those who scored ≤14 on the FMS had 2.74x greater probability of sustaining an injury during subsequent activity than those who scored >14”…so scores ≤14 are valid to indicate that there is increased risk for injury

40. Validity: Some studies showed that the FMS composite score is not as valid as is often used; Frost et al showed that educating those being screened on the criteria can significantly affect scores, suggesting that the scores may reflect more than physical characteristics (learned behavior) Comparisons with other measurements of movement and balance also did not find a correlation to FMS scores Therefore, more studies are needed to confirm the screen’s validity in predicting injury

41. Where does that leave us? More quality studies need to be conducted to determine the validity of the FMS and its ability to predict injuries in specific athletic populations However, obvious asymmetries in movement patterns may point us in a direction to start May pay closer attention to asymmetrical scores than composite score- asymmetries are something we can detect and address Further goniometric, strength and special testing may be needed Would be beneficial to see studies relating the FMS and return to sport

42. References Bonazza, Nicholas A., et al. "Reliability, Validity, and Injury Predictive Value of the Functional Movement Screen A Systematic Review and Meta-analysis." The American journal of sports medicine (2016): 0363546516641937. Cook, Gray. Athletic Body in Balance. Champaign, IL: Human Kinetics, 2003. Print. Cook, G., Burton, L., & Fields, K. (2009). The Functional Movement Screen and Exercise Progressions Manual. www. functionalmovement, com. Frost, D. M., Beach, T. A., Callaghan, J. P., & McGill, S. M. 2015. FMS Scores Change With Performers' Knowledge of the Grading Criteria—Are General Whole-Body Movement Screens Capturing “Dysfunction”?. The Journal of Strength & Conditioning Research, 29(11), 3037-3044.

43. Garrison, M., Westrick, R., Johnson, M. R., & Benenson, J. (2015). Association between the functional movement screen and injury development in college athletes. International journal of sports physical therapy, 10(1). Kiesel, K. B., Butler, R. J., & Plisky, P. J. (2014). Prediction of injury by limited and asymmetrical fundamental movement patterns in american football players. Journal of sport rehabilitation, 23(2). Mokha, M., Sprague, P. A., & Gatens, D. R. (2016). Predicting Musculoskeletal Injury in National Collegiate Athletic Association Division II Athletes From Asymmetries and Individual-Test Versus Composite Functional Movement Screen Scores. Journal of athletic training, 51(4), 276-282.