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An overview of movement screening in sport…

the good, the bad, and the ugly

Moran RW,1,4 Mason J,1 Schneiders AG,2 Major K,3 Sullivan SJ.4

1. Health Care (Osteopathy), Unitec Institute of Technology

2. Discipline of Physiotherapy, Central Queensland University

3. Private Practice, Osteopathy

4. Centre for Health, Activity, and Rehabilitation. University of Otago

• Background• Why we care about injury [apart from being paid]• Recap: injury aetiology models• Where movement quality might fit in injury aetiology

• Movement Screens• What’s available?, what claims?• FMS focus

• Systematic review findings re FMS

• Overview good, bad, ugly

• Bigger picture – ‘movement screening’ in context

• Q + A

Background

• Participation in physical activity is critical for the health of individualsand communities

• Compelling evidence that physical activity affords wide ranging health benefits [1-5]

However…

Background

• Increasing participation in sport and exercise is inevitably associated with increasing exposure to risk of injury [6]

• A large proportion of injuries (especially in overuse) are preventable [7]

Impact of injury

• Sport – lower injury rates predict team success in professional sport [8-9]

• Military (‘tactical athletes’) – injury impacts on operational readiness [10]

• Society – injury associated with disability, suffering, economic burden (direct costs of treatment, indirect costs of lost productivity) [11]

When people are injured, they lose the many benefits of participating in exercise…sometimes they don’t return to pre-injury levels of participation

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[12] Meeuwisse et al (2007)

Injury aetiology model

Movement quality

[12] Meeuwisse et al (2007)

Workload-injury aetiology model Windt & Gabbett, 2016

What is “movement quality”?

• Poorly defined in the literature – most research papers skirt around it

• A range of similar concepts and terminology in use

• Limited scholarly development – some ‘siloed thinking’?• eg physical literacy in physical education literature

Edwards et al. Definitions, foundations and associations of physical literacy: a systematic review. Sports Med 2017;47:113–26.

Movement Quality

“An individual’s ability to perform a specific movement task or

pattern in an optimal manner” - Kritz et al, 2009

Movement Quality

“An individual’s ability to perform a specific movement task or

pattern in an optimal manner” - Kritz et al, 2009

What does optimal mean?How to grade?How to record?…etc

Which movement tasks?How many?How fast?Loaded? Unloaded? Both?…etc

Responses to these and similar questions have lead to…

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>15

named

“screens”

Bennett et al. J Strength Cond Res. 2017 31(10):2903-19.

Bennett et al. J Strength Cond Res. 2017 31(10):2903-19.

54 tasks in

9 categoriesSquatHingeLungePushingPullingAbdominal bracingMobilityBalanceSport specific

Bennett et al Multiple component musculoskeletal movement assessment tools: A systematic review and critical appraisal of their development and applicability to professional practice. J Strength Cond Res. 2017 31(10):2903-19.

7 of the 11 multiple component tests reviewed by Bennett et al identified “predict injury risk” as an assessment objective...

Plenty of suggestion that these tests can play a role in injury prediction…is it true?

Most research interest = largest literature

Incorporated into other derivative eg 9+

Most common screen?eg McCall et al BJSM 2015 show widespread use in Euro premier football

Well organised commercial basis, marketing

400 lb ‘Shabani’ Nagoya Zoo, Japan

Let’s examine the FMS in some detail…because: A measure of ‘movement quality’ = Functional Movement Screen

[13] Cook, 2010

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Each of the 7 movements is scored against standardised criteria: 4 point ordinal0 = movement is painful

1 = movement is incomplete

2 = movement completed with [some] loss of balance, form, alignment

3 = movement is complete with no loss

Scoring

1

112

11

2

1

2

22

2

2

2

2

2

22

2

11/21

Basic interpretation?

Pain associated with any subtest? “stop”

Magnitude of asymmetry – left v right

Which movements? basic to complex Ex Rx

Composite score ≥ 14 and no asymmetries considered ‘movement baseline’ no further intervention

Kiesel et al (2007) Started it all…

Odds of 11.67 = ‘large’ effect

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mb

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ub

Med

Conducted two systematic reviews…

Systematic Review 1

Reliability - Can practitioners agree on FMS findings? [boring but necessary]

Systematic Review 2

“Prediction” - Is the strength of association between FMS scores and injury risk sufficiently high to justify use as a “prediction tool” ? [the sexy stuff]

To critically appraise and synthesise studies investigating (1) rater reliability,and (2) the strength of association between FMS and subsequent injury

PRISMA flow ‘reliability’ = 12 studies

Reliability: methodological diversity…precludes meta-analysis

Moran et al, 2016

Intra-rater reliability…Can practitioners agree with themselves?

‘moderate’ evidence of satisfactory intra-rater reliability

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Inter-rater reliability…Can different practitioners agree with each other?

‘moderate’ evidence of satisfactory inter-rater reliability

OK, so reliability is acceptable…but can FMS “predict” injury?

boring

PRISMA flow ‘validity’ = 23 studies

Quality of Cohort Studies ‘Q-Coh’ [16] Jarde et al, 2013

0 20 40 60 80 100

6. Attrition

5. Outcome measures

4. Maintenance of comparability

3. Exposure measure

2. Comparability of groups

1. Sample representativeness

Satisfied Not Satisfied

Proportion (%) of studies satisfying or not satisfying each QCoh domain

8 Good and

Acceptable

16 low

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Sport

Military

‘Smallest worthwhile effect’ - defined

Odds Ratio ≥ 1.5 ‘small’ effect

Risk Ratio ≥ 1.1 ‘small’ effect

Area Under Curve (ROC) ≥ 0.70

Likelihood Ratio ≥ 2 (change in post-test odds of ~ 15%)

Inference is clear when lower limit of CI exceed these thresholds

Strong evidence (3 high quality studies) of a ‘small’ effect (RR lower limit CI >1.1)

Military males – meta-analysisMilitary – female

Limited

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American Football

Conflicting

Collegiate sports – mixed cohorts

Conflicting

High School sports – mixed cohorts

Limited

Basketball – NBA and University

Limited

Ice Hockey – youth

Limited

Running

Limited

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Military – male

Strong

Strength of association between FMS composite score and injury?

The overall level of evidence was ‘limited’ or ‘conflicting’ for a wide range of athletic populations including running, ice hockey, collegiate and high school sport, and professional or collegiate American football.

Football (soccer)

“In football (soccer), the magnitude of effect was ‘unclear’ and there was ‘moderate’ evidence to recommend against the use of FMS composite scores for the purpose of injury prediction.”

In football (soccer), the magnitude of effect was ‘unclear’ and there was ‘moderate’ evidence to recommend against the use of FMS composite scores for the purpose of injury prediction.

Recent study of 44 Premier League teams shows ~80% use FMS for injury risk testing

[17] McCall et al, 2015 BJSM

Main findings?

• The strength of association between FMS composite scores and subsequent injury was not sufficient to recommend use as an injury prediction tool in the sports reviewed.

• In male military personnel, there was ‘strong’ evidence that the strength of association between composite score (cut-point ≤14/21) and subsequent injury was ‘small’.

• There was ‘moderate’ evidence to recommend against the use of FMS composite scores as an injury prediction test in football (soccer).

• Likely not worthwhile as an injury prediction test (composite score)

Image: Neny Dee https://www.youtube.com/watch?v=nNtoV3NrswQ

Objective “good” – hard data

Subjective “good” – soft benefits

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Objective “good” – hard data

We tend to make rapid, falsely dichotomous judgements: Good v Bad

Reminder: Systematic reviews often address very narrow and specific questions. We need to interpret the findings accordingly – not beyond the findings

Online response to our “injury risk” paper was interesting… many using our narrow conclusion (composite scores) to broadly dismiss movement screening completely

Adoption and rejection cycle is quite rapid in sports medicine (and physiotherapy generally)… turbulent ride for ourselves and our patients

Subjective “good” – soft benefits

Per the instructions, FMS offers a standardised, systematic approach that requires no technology [broomstick + roll of tape + measuring tape]

For novice practitioners (and for students), the structure offered by ’movement screens’ are a solid starting point

In strength & conditioning, basic movement screen (perhaps one with loading!) might usefully inform exercise prescription and help promote referral for pain that might otherwise be overlooked

Having a standardized and systematic approach to identify the presence of painful movement (“pain face”) is useful when the athlete isn’t a great historian (or doesn’t admit minor injury/niggle)

1. Does the FMS ‘composite score’ stack up as an index?

2. Have researchers and critics been playing a game of “straw man”?

Question: Statistically speaking, is it OK to add all these separate tests up into a single ‘composite score’?

877 male 57 femaleUS Marine officer candidates

147 male 143 femaleChinese national Olympic team @London games

88 male 88 femaleCollegiate athletes

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Statistically speaking, is it OK to add all these separate tests up into a single ‘composite score’?

No! 2 components, don’t add the 7 tests together

Maybe?1 or 2

components

No! 2 components, don’t add the 7 tests together FMS composite scores?…

just because we can, doesn’t mean we should

Are we refuting an argument that wasn’t proposed by the FMS developers?

Despite 24+ studies for “prediction”, only a few exploring these…

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Published 22 Aug 2017

2154 male soldiers over 6 months

Pain as a risk factor?

Alemany et al 2017 (In Press) Functional Movement Screen: Pain versus composite score and injury risk. J Sci Med Sport http://dx.doi.org/10.1016/j.jsams.2017.08.001

Pain as a risk factor?

Alemany et al 2017 (In Press) Functional Movement Screen: Pain versus composite score and injury risk. J Sci Med Sport http://dx.doi.org/10.1016/j.jsams.2017.08.001

Pain as a risk factor?

Just wondering… if an athlete says “yes, pain on that movement”, then at some level, aren’t we just saying “I’m already injured” even if the athlete doesn’t meet some formal definition for injury (eg time loss, or medical attention).

Moves away from ‘movement quality’ altogether?

+ve pain similar to poor composite score [in their sample]

Pain as a risk factor?

L v R Asymmetry as a risk factor?

238 NFL players, pre-season

L v R Asymmetry as a risk factor?

84 Collegiate athletes, ~1yr

Asymmetry or a 1: RR = 2.73 (95% 1.36, 5.4)

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FMSLoad

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HRV

Re

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Psych

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Tissue

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Pre

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Thinking about application – who?, what? when? where? why?…etc

5 Ws

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Prof John Sullivan

Prof Tony Schneiders

Kate Major

Jesse Mason

Acknowledgements

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