Inter-tester Reliability Study of the Functional Movement Screen (FMS TM ) Mariam Pashtoonwar, Anang Chokshi, Lindsay Blaauw, Cesar Fajardo Kaiser Permanente Sports and Extremities Fellowship

Contents Description of FMS TM Evidence for FMS TM Description of Testing Procedure Inter-tester Reliability Results

Functional Movement Screen (FMS TM ) Tests and grades 7 fundamental movements Football pre-season movement screen Compares asymmetry of body side to side Useful for both sports and non- sports patient populations

Functional Movement Screen (FMS TM ) 7 Fundamental Movement Tests 1)Deep Squat 2)Hurdle Step 3)In-line Lunge 4)Shoulder Mobility 5)Active Straight Leg Raise (SLR) 6)Trunk Stability Push Up 7)Rotary Stability

1.) Deep Squat Instructions: Stand with feet shoulder width apart. Hold the stick over your head with your shoulders in a “V” position, elbows straight. Squat down as far as you can and try to keep your heels on the floor with your head and chest facing forward. Grading: III: Subject able to squat down with heels on ground & chest/head facing forward. Arms directly over ahead. II: Proper form as stated above with 2x6 under heels I: If they cannot complete the movement properly

2.) Hurdle Step * Can be performed up to 3 times bilaterally The hurdle should be aligned with the height of the subject’s tibial tuberosity. Instructions: Place your feet together with your toes aligned touching the base of the 2x6. Place the stick behind your head across your shoulders and below your neck. Slowly step over the hurdle with one leg and touch your heel to the floor, making sure your standing leg stays straight. Then return your moving leg to the starting position. Repeat with the other leg. Grading: III: Subject able to complete bilaterally with no twisting or compensatory movement II: Subject compensated in some way by twisting, leaning or moving the spine I: Subject has loss of balance or if contact is made with the hurdle.

3.) In-Line Lunge *Can be performed up to 3 times bilaterally Measure subject’s tibia length (from floor to the tibial tuberosity (in centimeters)). A 2x6 board is placed on the floor. Using the tibia length a mark is made on the board from the end of the subjects toes. Instructions: Place your left heel on the end of the board. Hold the stick behind your back with your left hand behind your neck and your right hand at your tailbone. Keep the stick in contact with your head, mid-back and tailbone to keep your back straight. Step forward with your right foot placing your heel at the indicated mark. Bend both knees until your back knee touches the board. Return to starting position. Repeat with opposite leg and opposite hand holds Grading: III: Subject able to complete bilaterally with no twisting or compensatory movement II: Subject compensated in some way by twisting, leaning or moving the spine I: Subject has loss of balance or unable to complete

4.) Shoulder Mobility The subject’s hand will first be measured (in centimeters) from the distal wrist crease to the tip of the third digit. Instructions: Place both hands in a fist. Reach with one arm overhead as far as you can. With the other fist reach behind your back towards the other fist. Instructions for the clearing exam: Place one hand on the opposite shoulder and point your elbow upward. Repeat with the other hand. Ask “Any pain?” Grading: III: Subject’s fists are within one hand length II: Subject’s fists are within 1 ½ hand lengths I: Subject’s fists fall outside this length. Zero: Pain with clearing test (done at end of the test)

5.) Active Straight Leg Raise *Can be performed up to 3 times bilaterally Place a 2x6 board on the floor. (Place a dowel perpendicular at the midpoint of the ASIS and the midpoint of the patella at the thigh.) Instructions: Lie on your back with your head flat and your arms straight with your palms up and the back of your knees on the board. Lift your leg with your ankle flexed and your knee straight and keep your other knee in touching the board. Repeat with the other leg. Grading: III: If subject’s malleolus of the raised leg is located past the dowel If malleolus does not pass the dowel then the dowel is aligned along the medial malleolus of the test leg, perpendicular to the floor. II: If this point is between the thigh midpoint and the patella I: If this point is below the knee

6.) Trunk Stability Push Up Instructions: Begin in a push-up position with your feet together For a male: Place your hands down on the floor, shoulder width apart with your thumbs at forehead height For a female: Place your hands down on the floor, shoulder width apart with your thumbs in line with your chin. With your knees straight and on your toes, perform one push-up while keeping your back straight. Clearing Test Instructions: Begin face-down on the floor propped on your elbows. Press up onto your hands extending your back. Grading: III: Complete one (1) pushup without lumbar spine lag If the push up cannot be performed the hands are lowered with the thumbs aligning with the chin for males and the clavicles for females II: Complete one (1) pushup with lumbar spine lag at modified hand position I: Subject is unable to complete the test Zero: Pain with clearing test (done at end of the test)

7.) Rotary Stability *Can be performed up to 3 times bilaterally Instructions: Begin on your hands and knees with your hands in line with your shoulders and your knees in line with your hips. (PT places a 2x6 board between their hands and knees so they are in contact with the board). Reach forward with your right arm and at the same time straighten out your right leg behind you only about 6 inches off the floor. Keep your arm and leg aligned with the board. Then bring the leg and arm together until the elbow and knee touch. Repeat with the other arm and leg. If the subject cannot perform the movement above: Tell them to “Do the same movement using opposite arm and leg. For example, right elbow to the left knee while keeping your back straight. Grading: III: Hand and knee remain in line with the 2x6 as well as the torso and they complete the movement with same side arm and leg. II: Hand and knee remain in line with the 2x6 as well as the torso and they complete the movement with the opposite arm and leg. I: If loss of balance occurs or they cannot perform either movements bilaterally.

EBP: Can Serious Injury In Professional Football Be Predicted By A Preseason Functional Movement Screen? (NAJSPT August 2007) Kyle Kiesel, PT, PhD, ATC, CSCS Philip J. Plisky, PT, DSc, OCS, ATC Michael L. Voight, PT, DHSc, OCS, SCS

Purpose of Study To examine the relationship between the relationship between professional football players’ score on the FMS TM and the likelihood of a player suffering a serious injury over the course of one competitive season.

Materials and Methods Retrospective Study N=45 professional football players All players tested on FMS TM Surveillance time for study: one full football season (4.5 months)

Results of Data Cut off score that maximized specificity and sensitivity of receiver-operated characteristic (ROC) was 14 Specificity =.91 Sensitivity =.54 Odds Ratio = Negative likelihood ratio =.51

Conclusion If a player scored < 14: –51% chance of suffering an injury –Eleven fold increased chance of injury when compared to players who had a higher score

Purpose of Current Study There is some evidence that shows the FMS is useful to predict serious injury in football players Question: What is the Inter-tester Reliability of the Functional Movement Screen?

Testing Procedure for Study Subjects: High School Football Players All subjects are Males aged All players tested on FMS TM Data gathered on: Age, Weight, Height, Position, BMI, Previous Injury

Testing Procedure for Study One Physical Therapist administered test Instruction was given only by this one therapist Three other physical therapists scored each subject independently (Scorers A-C) Scores were not shared between therapists during or post testing

Data Collection Scoring for the FMS TM based on procedure delineated by Cook, Burton and Hoogenboom 1 Each score was recorded for 7 individual tests of FMS TM

Data Analysis Plan Total Number of Football Players Tested N = 18 Statistical Analysis Used: –Kappa Coefficient

Kappa Coefficient Statistical measure of inter-rater agreement Takes into account the agreement occurring by chance Possible values range from +1 (perfect agreement) to 0 (no agreement above that expected by chance) to -1 (complete disagreement)

Kappa’s Coefficient Cont’d… Kappa = (observed agreement - chance agreement)/(1-chance agreement)

Kappa Strength (from Landis and Koch, 1997) KappaStrength of Agreement 0.00Poor Slight Fair Moderate Substantial Almost Perfect

Our Kappa Results Average Kappa per Test: 1.) Deep Squat = 63%= Substantial 2.) Hurdle Step = 34%= Fair 3.) In-Line Lunge = 56%= Moderate 4.) Shoulder Mobility = 85%= Almost Perfect 5.) Active Straight Leg Raise = 77%= Substantial 6.) Trunk Stability Push Up = 81%= Almost Perfect 7.) Rotary Stability = 53%= Moderate

Observed agreement = 12/18 = 66.7% A B IIIIIII 2IIIIIIII 3III

Our Results Cont’d… Highest Inter-Rater Reliability for Shoulder Mobility Test, Trunk Stability Push Up, Active Straight Leg Raise and Deep Squat Inter-Rater Reliability lowest for Hurdle Step

Discussion Higher Inter-Rater Reliability for shoulder mobility and ASLR possibly due to more objective measure, less variability Lower Inter-Rater Reliability for Hurdle Step, In- Line Lunge and Rotary Stability secondary to more subjective interpretation Variability in grading secondary to lack of experience with the tests (i.e. increased variability between Caesar’s scores vs. Mariam and Anang’s)

Conclusion Overall, FMS is a reliable test: average of all tests=moderate strength Ways to minimize difference in testers’ scores: -all testers observe subject from same place (i.e. frontal plane, sagittal, etc) -testers should be equally trained

References 1.Cook G, Burton L, Hoogenboon B. Pre- participation screening: The use of fundamental movements as an assessment of function – Part 1. NAJSPT May 2006:1: Kiesel K, Plisky P J, Voight M L. Can Serious Injury In Professional Football Be Predicted By A Preseason Functional Movement Screen? NAJSPT August :