Inter-tester Reliability Study of the Functional Movement Screen (FMSTM)

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Inter-tester Reliability Study of the Functional
Movement Screen (FMSTM)

• Mariam Pashtoonwar, Anang Chokshi, Lindsay
  Blaauw, Cesar Fajardo
• Kaiser Permanente Sports and Extremities
  Fellowship

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Contents

• Description of FMSTM
• Evidence for FMSTM
• Description of Testing Procedure
• Inter-tester Reliability Results

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Functional Movement Screen (FMSTM)

• 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

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Functional Movement Screen (FMSTM)

• 7 Fundamental Movement Tests
• Deep Squat
• Hurdle Step
• In-line Lunge
• Shoulder Mobility
• Active Straight Leg Raise (SLR)
• Trunk Stability Push Up
• Rotary Stability

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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
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2.) Hurdle Step
Can be performed up to 3 times bilaterally The
hurdle should be aligned with the height of the
subjects 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.
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3.) In-Line Lunge
Can be performed up to 3 times
bilaterally Measure subjects 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
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4.) Shoulder Mobility
  The subjects 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 Subjects fists are within one
hand length   II Subjects fists are within 1
½ hand lengths   I Subjects fists fall
outside this length.   Zero Pain with clearing
test (done at end of the test)
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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 subjects 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
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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)
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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.
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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

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Purpose of Study

• To examine the relationship between the
  relationship between professional football
  players score on the FMSTM and the likelihood of
  a player suffering a serious injury over the
  course of one competitive season.

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Materials and Methods

• Retrospective Study
• N45 professional football players
• All players tested on FMSTM
• Surveillance time for study one full football
  season (4.5 months)

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Results of Data

• Cut off score that maximized specificity and
  sensitivity of receiver-operated characteristic
  (ROC) was 14
• Specificity .91
• Sensitivity .54
• Odds Ratio 11.67
• Negative likelihood ratio .51

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Conclusion

• If a player scored lt 14
• 51 chance of suffering an injury
• Eleven fold increased chance of injury when
  compared to players who had a higher score

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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?

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Testing Procedure for Study

• Subjects High School Football Players
• All subjects are Males aged 14-16
• All players tested on FMSTM
• Data gathered on Age, Weight, Height, Position,
  BMI, Previous Injury

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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

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Data Collection

• Scoring for the FMSTM based on procedure
  delineated by Cook, Burton and Hoogenboom1
• Each score was recorded for 7 individual tests of
  FMSTM

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Data Analysis Plan

• Total Number of Football Players Tested
• N 18
• Statistical Analysis Used
• Kappa Coefficient

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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)

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Kappas Coefficient Contd

• Kappa (observed agreement - chance
  agreement)/(1-chance agreement)

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Kappa Strength

• (from Landis and Koch, 1997)

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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

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Observed agreement 12/18 66.7

• A
• B 7
• 8
• 3
• 5 10 3

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Our Results Contd

• 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

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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 Caesars scores vs. Mariam
  and Anangs)

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Conclusion

• Overall, FMS is a reliable test average of all
  testsmoderate 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

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References

• Cook G, Burton L, Hoogenboon B. Pre-participation
  screening The use of fundamental movements as an
  assessment of function Part 1. NAJSPT May
  2006162-71
• Kiesel K, Plisky P J, Voight M L. Can Serious
  Injury In Professional Football Be Predicted By A
  Preseason Functional Movement Screen? NAJSPT
  August 2007 2147-151