Functional Movement Screen TM â Normative Values ...

Orthopedics & Biomechanics

Authors

C. Agresta, M. Slobodinsky, C. Tucker

Affiliation

Department of Physical Therapy, Temple University, Philadelphia, United States

Key words ▶ functional movement ● ▶ distance runners ● ▶ injury ●

Abstract

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Recreational runners have an estimated overuse injury incidence rate of up to 79 % and 90 % for marathoners. A pre-participation screening tool that can identify risk for injury may help reduce overuse injury in runners. The Functional Movement Screen (FMSTM) is a reliable clinical tool used with athletes to help predict injury. To date, the FMSTM has not been used with endurance athletes. The purpose of this article is to establish normative FMSTM values for distance runners. 45 healthy runners performed the FMSTM. Descriptive statistics were calculated; independent t-tests were performed to examine

Introduction

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accepted after revision April 30, 2014 Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1382055 Published online: 2014 Int J Sports Med © Georg Thieme Verlag KG Stuttgart · New York ISSN 0172-4622 Correspondence Cristine Agresta Physical Therapy Temple University 3307 N Broad St, 19140 Philadelphia United States Tel.: + 1/215/707 4877 Fax: + 1/215/707 4897 [email protected]

Physical inactivity is a significant public health concern and poses a major health risk for sedentary individuals [3]. In response, a growing number of individuals participate in recreational activities, namely distance running, for exercise and fitness. Recreational running has a number of health benefits, including reduced risk of mortality, and has a dose-response relationship where higher levels of physical exercise have a greater protective effect [37]. In 2010, an estimated 36 million individuals in the US ran recreationally with over 500 000 completing a marathon [20]. Overuse running-related injuries have the potential to significantly disrupt participation in physical activity and racing. Distance runners are at a high risk for injury, with the incidence of lower extremity running-related injury rates ranges from 19.4 % to 79.3 % [39, 40]. Mechanisms for overuse injury in runners can be seen as falling into 3 distinct categories: structure, mechanics, and dosage. The association between structure or alignment and overuse running-related injuries has demonstrated little consistency [21, 42, 43],

the effect of gender, experience and injury on scores. A Chi-square test was used to evaluate whether significant differences in scores exist for any component of the FMSTM. The mean FMSTM score was 13.13 ± 1.8. No significant differences in FMSTM scores were found between novice and experienced runners (p = 0.71) or runners with a history of injury and those without (p = 0.20). While male and female runners did not differ significantly in their total FMSTM score (p = 0.65), significant differences were found in the deep squat (p < 0.05), trunk stability push-up (p < 0.001) and active straight leg raise components (p = 0.002). This study provides normative values for FMSTM scores when testing uninjured distance runners.

although some have found a significant link between type of injury, bony vs. soft tissue, and arch index [45]. While there is some evidence to support increased running volume or dosage associated with injury, the relationship is complex and still not well understood [22, 41]. The lack of strong support for either of these categories may be due to the multifactorial etiology of overuse injuries. Altered lower extremity kinematics may play a major role in knee injury [31, 32], which is the most commonly injured area for runners [39, 40]. Increases in impact force have also been linked to overuse injury, with a recent review [50] reporting that runners with a history of tibial stress fractures demonstrated higher vertical ground reaction force loading rates than control groups. However, these results were contrary to other findings [25]. Thus, the relationship between impact force, vertical loading rate and running injuries remain unclear [34]. Evaluation of running mechanics typically requires the use of laboratory equipment and an experienced examiner, which is often unavailable in typical clinical settings. Several researchers have advocated for a clinical screening process whereby practitioners

Agresta C et al. Functional Movement ScreenTM –. Int J Sports Med

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Functional Movement ScreenTM – Normative Values in Healthy Distance Runners

could identify runners at risk for injury [14, 41]. To date, however, no screening tool has been used or validated that identifies risk of overuse injury in runners. The Functional Movement Screen (FMSTM) is a screening tool used to simultaneously assess multiple domains of function (balance, strength, range of motion) and may improve the accuracy of identifying athletes risk to injury [28]. The screen tests fundamental movement patterns required for sports. The screening tool consists of 7 tests that utilize a variety of basic positions and movements, which are thought to provide the foundation for more complex athletic movements to be performed efficiently. These included functional mobility of the lower extremity joints, tests that examine stride mechanics, the interplay between distal mobility and proximal stability, and multi-plane movements [7, 8]. The FMSTM has been validated in several athletic populations during competitive seasons and may provide a method for clinically testing the multifactorial nature of injury and risk determinants [19, 27]. The FMSTM has yet to be evaluated and used in endurance sports, particularly with distance runners. Therefore, the purpose of this study was to establish normative values for the FMSTM in a population of distance runners. Secondary aims were to investigate whether performance differed between males and females, those with and without a previous history of injury, and running experience. We hypothesized that runners with less experience and those with prior history of injury would present with lower scores on the FMSTM. We did not expect that there would be a difference in scores between male and female runners.

Methods

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Participants 45 healthy runners (24 M; 21 F mean age = 34.8 ± 7.7) between the ages of 22 and 54 years volunteered for this study. Participants were recruited from local running clubs in the Chicago area. Subjects were included in the study if they were currently training for a full or half-marathon, were injury-free for at least 3 months prior to testing, had no history of surgery within the last 6 months and were willing to be contacted through email for the study. An injury was defined as “any physical complaint developed in relation with running activities and causing a restriction in running distance, speed, duration, or frequency”. This definition was taken from Bovens et al. [4]. Subjects were excluded if they were elite or professional endurance athletes. Runners were considered to be elite if they had met the qualifying time for Olympic Trials or made outstanding accomplishments in distance running events in the past 2 years prior to testing [5, 30]. The study was performed in accordance with the ethical standards of the Int J Sports Med [10], and was approved by the Temple University Human Ethics Committee and the Chicago Area Runner’s Association Review Board. Written consent was obtained prior to data collection. Subjects were grouped into either novice or experienced runners. Novice runners were those who had 3 or less years running experience, while experienced runners were those who have more than 3 years experience running, as runners with less than 3 years experience have an increased risk of injury [11, 41].

Procedures Data collection took place at local running sites and training events. Participants wore their usual athletic clothing and footAgresta C et al. Functional Movement ScreenTM –. Int J Sports Med

wear for the study. Licensed physical therapists and an athletic trainer collected the data, and a certified FMSTM instructor trained the investigators to perform the screen prior to data collection with subjects. The 7 components of the FMSTM screening tool consist of whole-body movements that are meant to assess mobility and strength simultaneously. They include a deep squat, a hurdle step, an in-line lunge, a shoulder mobility test, an active straight leg raise test, a trunk stability push-up, and a rotary stability test. For more details about each component and the FMSTM, please refer to Cook et al. [7, 8]. The FMSTM has been shown to have excellent inter-rater reliability for composite scores (ICC = 0.971) and between individual test components (k = 0.70–1.0) [36]. Reliability for novice and expert raters has also been tested. Neither pair of raters fell below a moderate level of agreement. The novice raters had excellent agreement on 2 more test components when compared with the expert raters (6 vs. 4), although the percent agreement was similar (89.6 and 86.7 % for novice and expert raters, respectively). When the novice raters were compared with expert raters, 14 of the 17 tests had excellent agreement [24].

Functional Movement ScreenTM Testing The FMSTM screening instructions and scoring process associated with the standardized version of the test were followed in order to ensure scoring accuracy and consistency across test administrators. Test components were not randomized. Each participant was given 3 trials for the deep squat, and 2 trials for the hurdle step, in-line lunge, trunk stability push-up, and rotary stability test. Subjects were given one trial for shoulder mobility and active straight leg raise. Each trial was scored on a scale from zero to 3. A score of 0 indicated that pain was reported during the movement or the participant was unable to get into the test position and perform the movement; a score of one indicated failure to complete the movement or loss of balance during the test; a score of 2 indicated that the movement was performed with compensation; and a score of 3 indicated perfect form during the movement. For test components in which right and left side scores were recorded, the lower of the 2 scores was carried over as a final score for that component of the FMSTM. In addition to the 7 test components, 3 clearing exams (active scapular stability or impingement test, spinal extension and spinal flexion clearing) were performed and scored as either positive or negative with a positive response indicating that pain was reproduced during the examination movement. If subjects were positive for any clearing exams, they received a zero for the corresponding FMSTM component movement. Final scores for each component were added to obtain an overall composite FMSTM score with a maximum value of 21.

Data analysis Descriptive statistics were calculated for patient demographics that included age, anthropometrics, years running and gender. Independent t-tests were performed to examine differences between male and female runners, those who had a prior injury in the last 12 months and those who were novice vs. experienced runners. Chi-square tests were used to evaluate if there were any significant differences between males and females in the distribution of scores for the different tests. All calculations were performed using Stata 12.1/IC software (StataCorp. 2009. Stata Statistical Software: Release 12. College Station, TX: StataCorp LP) and the a priori level of significance was set at p ≤ 0.05.



Results

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22 runners (51 %) reported that they had a running-related injury in the past 12 months with several runners reporting more than one injury. Descriptive data for subjects are available ▶ Table 1, with injury locations being listed in ● ▶ Table 2. Subin ● jects completed all components of the FMSTM, including clearing tests for pain. Of the 45 subjects, 6 reported pain with the impingement clearing test, 5 with the press-up clearing test, and zero with the posterior rocking clearing test. The mean composite FMSTM score was 13.13 ± 1.8 out of a maximum of 21. Runners had the highest scores for the in-line lunge component with a mean score of 2.17 ± 0.53 and scored lowest on the rotary stability component where the mean score was 1.62 ± 0.49. The ▶ Table 3. descriptive data for FMS scoring can be found in ● Male and female runners did not differ significantly in their total FMSTM score (p = 0.65), with the total score for males being 13.08 ± 1.64 and for females 13.33 ± 1.9. However, significant differences for gender were found for 3 FMSTM components – the Table 1 Patient demographics. Running experience

gender male female age (years) weight (kg) height (cm) running experience (years) prior history of injury

All (n = 45)

Novice

Experienced

(0–3 years)

(3 + years)

(n = 14)

(n = 31)

48 % 52 % 32.1 ± 8.5 68.1 ± 13.6 169.3 ± 10.2 2.2 ± 0.80

57 % 43 % 36.1 ± 7.0 70.6 ± 13.8 172.1 ± 10.5 10.7 ± 5.4

52 % 48 % 34.8 ± 7.7 69.8 ± 13.6 171.2 ± 10.4 7.9 ± 6.0

42 %

55 %

51 %

Table 2 The location of injury for previously injured runners. Injury location

Count

knee thigh hip calf ankle achilles foot toe

5 4 6 1 2 1 8 1

Percentage ( %) 9.8 7.8 11.8 2.0 3.9 2.0 15.7 2.0

deep squat (chi-square = 6.198, p = 0.045), trunk stability pushup (chi-square = 18.49, p < 0.001), and active straight leg raise (chi-square = 12.78, p = 0.002). For the deep squat, the majority of men (78.3 %) and women (66.7 %) score a ‘2’. 13 % of men scored a ‘3’ on the deep squat, while no women scored a ‘3’. The majority of women (61.9 %) scored a ‘1’ on the trunk stability push-up component, while the majority of men (47.8 %) scored a ‘2’. Again, no women scored a ‘3’ on the trunk stability push-up test, while 43.5 % of men scored a ‘3’. On the active straight leg raise component, the majority of women (57.1 %) scored a ‘3’, while only 8.7 % of men received the same score. The most common score for men (65.2 %) was a ‘2’. Differences in FMSTM scores between runners with prior history of injury in the last 12 months were also determined. In those who had experienced an injury in the past 12 months, the mean FMSTM score was 13.59 ± 0.40, while runners without a history of injury had mean FMSTM score of 12.9 ± 0.34. No significant differences were found between runners with a history of injury and those without for the mean composite score (p = 0.202) or for any component of the FMSTM test. Differences in FMSTM scores were compared between novice and experienced runners. Novice and experienced runners did not differ significantly in their FMS scores (p = 0.708), with novice runners averaging 13.28 ± 0.41 and experienced runners averaging 13.06 ± 0.35 for their total FMSTM scores. No significant differences were found between novice and experienced runners for any component of the FMSTM test.

Discussion

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The purpose of this study was to establish normative values for the FMSTM in a population of distance runners and to determine if differences exist between males and females, those with and without history of running injury, and between novice and experienced runners. Several studies have reported higher injury rates in inexperienced runners [6, 11, 33, 35, 41]. In addition, the idea that runners may get injured not because of how or how much they run but because of the strength of their musculoskeletal tissues has been proposed [13]. While we expected to see significantly lower FMSTM scores for runners with a history of injury and for inexperienced runners, our findings did not support this claim. Our findings were similar to Schneiders et al. [36], who performed the FMSTM on 209 young, active adults. They did not find a significant difference in scores for gender or those with a history of injury. Interestingly, the mean composite score in their population was 15.7, which is slightly higher than our finding of

Table 3 Functional Movement Screen (FMSTM) test scores for distance runners. Deep squat Gender male 2.0 ± 0.47* female 1.7 ± 0.48* Experience level novice 1.7 ± 0.47 experienced 1.9 ± 0.51 Prior history of injury yes 1.9 ± 0.53 no 1.8 ± 0.51

Hurdle step

In-line lunge

Shoulder

Active straight

Trunk stability

Rotary

mobility

leg raise

push-up

stability

Total

2.0 ± 0.47 1.7 ± 0.54

2.1 ± 0.51 2.3 ± 0.67

1.7 ± 0.96 2.3 ± 0.72

1.8 ± 0.58* 2.5 ± 0.60*

2.3 ± 0.65** 1.4 ± 0.50**

1.5 ± 0.51 1.7 ± 0.44

13.1 ± 1.7 13.3 ± 1.9

2.0 ± 0.39 1.8 ± 0.54

2.3 ± 0.61 2.1 ± 0.50

2.3 ± 0.73 1.8 ± 0.93

2.2 ± 0.58 2.1 ± 0.72

1.8 ± 0.80 1.97 ± 0.75

1.8 ± 0.43 1.5 ± 0.51

13.3 ± 1.5 13.1 ± 1.9

1.9 ± 0.61 1.8 ± 0.40

2.1 ± 0.56 2.2 ± 0.54

2.0 ± 0.93 2.1 ± 0.77

2.1 ± 0.75 2.3 ± 0.56

2.1 ± 0.75 1.7 ± 0.73

1.6 ± 0.50 1.7 ± 0.48

13.6 ± 1.9 12.9 ± 1.5

*p < 0.05; **p < 0.001






[1, 2] as well as examining different training programs that focus on core and multi-planar functional strength vs. running only.

Conclusion

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This is the first study to provide normative data for the FMSTM on a cohort of distance runners. Our findings can serve as a standard for physical therapists and running coaches when evaluating the functional ability of uninjured distance runners. Future research is needed to refine our understanding of the utility of FMSTM as a screening tool for injury and baseline functional strength in distance runners.

Acknowledgements

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The authors would like to thank NovaCare Rehabilitation in Chicago and the Chicago Area Runners Association (CARA) for their invaluable contribution to subject recruitment for this study.

Conflicts of interest: The authors declare no conflict of interest. References 1 Bahr R, Holme I. Risk factors for sports injuries – a methodological approach. Br J Sports Med 2003; 37: 384–392 2 Bahr R, Krosshaug T. Understanding injury mechanisms: a key component of preventing injuries in sport. Br J Sports Med 2005; 39: 324–329 3 Blair S. Physical inactivity: The biggest public health problem of the 21st Century. Br J Sports Med 2009; 43: 1–2 4 Bovens A, Janssen G, Vermeer H, Hoeberigs J, Janssen M. Occurrence of running injuries in adults following a supervised training program. Int J Sports Med 1989; 10: S186–S190 5 Chapman RF, Laymon AS, Wilhite DP, McKenzie JM, Tanner DA, Stager JM. Ground contact time as an indicator of metabolic cost in elite distance runners. Med Sci Sports Exerc 2012; 44: 917–925 6 Chorley J, Cianca J, Divine J, Hew T. Baseline injury risk factors for runners starting a marathon training program. Clin J Sports Med 2002; 12: 18–23 7 Cook G, Burton L, Hoogenboom B. Pre-participation screening: the use of fundamental movements as an assessment of function – part 1. North Am J Sports Phys Ther 2006; 1: 62–72 8 Cook G, Burton L, Hoogenboom B. Pre-participation screening: the use of fundamental movements as an assessment of function – Part 2. North Am J Sports Phys Ther 2006; 1: 132–139 9 Fredericson M, Misra AK. Epidemiology and aetiology of marathon running injuries. Sports Med 2007; 37: 437–439 10 Harriss DJ, Atkinson G. Ethical standards in sports and exercise science research: 2014 update. Int J Sports Med 2013; 34: 1025–1028 11 Herzog W. Running injuries, is it a question of evolution, form, tissue properties, mileage, or shoes? Med Sci Sports Exerc 2012; 40 12 Hreljac A, Ferber R. A biomechanical perspective of predicting injury risk in running. Int Sports Med J 2006; 7: 98–108 13 Kibler W, Chandler T, Uhl T, Maddux R. A musculoskeletal approach to the preparticipation physical examination: Preventing injury and improving performance. Am J Sports Med 1989; 17: 525–531 14 Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Med 2006; 36: 189–198 15 Kiesel KB, Plisky P, Voight MI. Can serious injury in professional football be predicted by a preseason functional movement screen? North Am J Sports Phys Ther 2007; 2: 147–158 16 Lampaa R. Marathon, half-marathon and state of sport report. Colorado Springs, CO, Running USA: 2011 17 Lun V, Meeuwisse WH, Stergiou P, Stefanyshyn D. Relation between running injury and static lower limb alignment in recreational runners. Br J Sports Med 2004; 38: 576–580 18 Marti B, Vader JP, Minder CE, Abelin T. On the epidemiology of running injuries: The 1984 Bern Grand-Prix study. Am J Sports Med 1988; 16: 285–294


13.13. When compared to other athletic populations, mean composite score for distance runners is even lower. For example, the mean composite score for professional football players is 16.9 [19]. Lower scores on the FMSTM may be a reflection of the repetitive, single plane movement training (i. e., straight plane running) undertaken by most distance runners, as the FMSTM tests more multi-planar functional movements. This idea is further supported by our findings that distance runners scored highest for the inline lunge component, which is the movement pattern most similar to running, and poorest on the rotary stability test. While no significant differences were reported for gender, males scored significantly higher than females on the deep squat and trunk stability pushup. Although male athletes were reported to be stronger than females [17], the gender differential found between FMSTM components should be attributed to differences in core muscle activity rather than strength. This is because of the dynamic, functional and multi-planar nature of the FMSTM testing and the definition and evaluation of core stability [18]. Furthermore, gender differences in core stability may predispose female runners to injury [47] or poor mechanics during single leg activities [48]. In a study by Schneiders et al. [36], significant differences in rotary stability scores were reported between gender. Our study found no significant differences between genders in this component of the FMSTM. However, this was the lowest component score across all runners. The purpose of the rotary stability test is to assess complex movement requiring proper neuromuscular coordination and energy transfer from one segment of the body to another through the torso and requires adequate transverse plane stability [8]. Lower scores on this component may suggest that runners have impaired trunk, pelvis and hip muscular control, which is a contributing factor to abnormal lower extremity mechanics [26, 32]. Runners with a history of injury had higher mean composite scores than those without history of injury (13.59 vs. 12.9). While these differences were not significant, higher scores in previously injured runners may be a result of focused treatment, such as physical therapy or strength training, received for a particular injury. More information on current cross-training programs and previous treatment is needed to determine whether this is a contributing factor. This is the first study to evaluate FMSTM scores in distance runners. Our study had adequate power for determining normative values for the screen. However, one limitation of our study is its limited power to determine whether truly significant differences exist in our subgroups (i. e., gender, experience level, prior history of injury). Moreover, our sample size did not allow for analysis of contributing factors that may influence FMSTM scores. Further research is needed to substantiate our findings. Future studies should include larger sample sizes with a longitudinal design and control for risk factors such as mechanics, training factors, and alignment. The incorporation of clinical lower extremity functional screening tests such as the Small Knee Bend (SKB) and Frontal Plane Projection Angle (FPPA) may provide reliable information on lower extremity dynamic alignment without the need for sophisticated laboratory equipment [44,49]. In addition, we did not obtain information about strength training or other activities runners were performing or a history of treatment for prior injury. Future research should focus on the ability of baseline FMSTM score to predict injury in distance runners using a comprehensive model to assess risk

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Functional Movement Screen TM â Normative Values ...

Functional Movement Screen TM â Normative Values ...

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