[
]
research report
DEYDRE S. TEYHEN, PT, PhD1,2 • SCOTT W. SHAFFER, PT, PhD2 • CHELSEA L. LORENSON, PT3 • JOSHUA P. HALFPAP, PT3
DUSTIN F. DONOFRY, PT3 • MICHAEL J. WALKER, PT, DSc4 • JESSICA L. DUGAN, PT5 • JOHN D. CHILDS, PT, PhD2,6
The Functional Movement
Screen: A Reliability Study
TTSTUDY DESIGN: Reliability study.
TTOBJECTIVES: To determine intrarater test-
retest and interrater reliability of the Functional
Movement Screen (FMS) among novice raters.
TTBACKGROUND: The FMS is used by various
examiners to assess movement and predict timeloss injuries in diverse populations (eg, youth to
professional athletes, firefighters, military service
members) of active participants. Unfortunately,
critical analysis of the reliability of the FMS is
currently limited to 1 sample of active college-age
participants.
TTMETHODS: Sixty-four active-duty service
members (mean  SD age, 25.2  3.8 years;
body mass index, 25.1  3.1 kg/m2) without
a history of injury were enrolled. Participants
completed the 7 component tests of the FMS in a
counterbalanced order. Each component test was
scored on an ordinal scale (0 to 3 points), resulting
in a composite score ranging from 0 to 21 points.
Intrarater test-retest reliability was assessed
between baseline scores and those obtained with
repeated testing performed 48 to 72 hours later.
Interrater reliability was based on the assessment
from 2 raters, selected from a pool of 8 novice
raters, who assessed the same movements on day
2 simultaneously. Descriptive statistics, weighted
kappa (κw), and percent agreement were calculated on component scores. Intraclass correlation
coefficients (ICCs), standard error of the measurement, minimal detectable change (MDC95), and
associated 95% confidence intervals (CIs) were
calculated on composite scores.
TTRESULTS: The average  SD score on the FMS
was 15.7  0.2 points, with 15.6% (n = 10) of the
participants scoring less than or equal to 14 points,
the recommended cutoff for predicting time-loss
injuries. The intrarater test-retest and interrater
reliability of the FMS composite score resulted in
an ICC3,1 of 0.76 (95% CI: 0.63, 0.85) and an ICC2,1
of 0.74 (95% CI: 0.60, 0.83), respectively. The standard error of the measurement of the composite
test was within 1 point, and the MDC95 values were
2.1 and 2.5 points on the 21-point scale for interrater and intrarater reliability, respectively. The interrater agreement of the component scores ranged
from moderate to excellent (κw = 0.45-0.82).
TTCONCLUSION: Among novice raters, the FMS
composite score demonstrated moderate to good
interrater and intrarater reliability, with acceptable levels of measurement error. The measures
of reliability and measurement error were similar
for both intrarater reliability that repeated the
assessment of the movement patterns over a 48to-72–hour period and interrater reliability that had
2 raters assess the same movement pattern simultaneously. The interrater agreement of the FMS
component scores was good to excellent for the
push-up, quadruped, shoulder mobility, straight leg
raise, squat, hurdle, and lunge. Only 15.6% (n = 10)
of the participants were identified to be at risk for
injury based on previously published cutoff values.
J Orthop Sports Phys Ther 2012;42(6):530-540,
Epub 14 May 2012. doi:10.2519/jospt.2012.3838
TTKEY WORDS: injury prediction, injury prevention, injury risk, interrater, intrarater
M
ore than 10 000 Americans seek medical treatment for sports, recreational activity, and
exercise-related injuries on a
daily basis.20 Researchers have
estimated that 50% to 80% of
these injuries are overuse in
nature and involve the lower extremity.1,11,25 In the military, physical training
and exercise-related injuries account for
30% of hospitalizations and 40% to 60%
of all outpatient visits, with 10 to 12 injuries per 100 soldier-months.12 Although
the risk of musculoskeletal conditions
and injuries is multifactorial,7,9,10,15,17-19
preliminary evidence suggests that neuromuscular and strength training programs
may be beneficial for preventing the occurrence of these conditions.7,9,10,15,17-19
However, tools that assess movement
to help predict those at highest risk for
musculoskeletal conditions and injuries
have been lacking for both athletic and
military populations. The Functional
Movement Screen (FMS) is a relatively
new tool that attempts to address multiple movement factors, with the goal of
predicting general risk of musculoskeletal
Commander, US Army Public Health Command Region-South, Fort Sam Houston, TX. 2Associate Professor, US Army-Baylor University, Fort Sam Houston, TX. 3Physical Therapy
Intern, US Army-Baylor University, Fort Sam Houston, TX. 4Assistant Professor, US Army-Baylor University, Fort Sam Houston, TX. 5Researcher, TRUE Research Foundation, San
Antonio, TX. 6Director of Musculoskeletal Research, Department of Physical Therapy (MSGS/SGCUY), 81st Medical Group, Keesler Air Force Base, Biloxi, MS. This research
study was approved by the Brooke Army Medical Center Institutional Review Board. The views expressed herein are those of the authors and do not reflect the official policy or
position of Brooke Army Medical Center, the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Army, Department of the Air Force,
Department of Defense, or the US Government. Address correspondence to Dr Deydre S. Teyhen, US Army-Baylor University, 3151 Scott Road, Room 1303 (ATTN: MCCS-HGEPT), Fort Sam Houston, TX 78234. E-mail: dteyhen@gmail.com or Deydre.teyhen@us.army.mil
1
530 | june 2012 | volume 42 | number 6 | journal of orthopaedic & sports physical therapy
42-06 Teyhen.indd 530
5/22/2012 5:38:56 PM
conditions and injuries.3-5,13,14,16
The FMS was designed to identify
functional movement deficits and asymmetries that may be predictive of general
musculoskeletal conditions and injuries,
with an ultimate goal of being able to
modify the identified movement deficits
through individualized exercise prescription.3,4 The FMS consists of 7 fundamental movement component tests (FIGURE 1)
that are scored on a scale of 0 to 3, with
the sum creating a composite score ranging from 0 to 21 points.3,4 The 7 movement patterns that are assessed include
the deep squat, in-line lunge, hurdle
step, shoulder mobility, active straight leg
raise, trunk stability push-up, and quadruped rotary stability.
Preliminary research by Kiesel et al14
suggests that National Football League
(NFL) players (n = 46) who had a composite score less than or equal to 14 on
the FMS had an odds ratio of 11.7 (95%
confidence interval [CI]: 2.5, 54.5) and a
positive likelihood ratio of 5.8 (95% CI:
2.0, 18.4) to sustain a time-loss injury. Although the specificity was relatively high
(0.9; 95% CI: 0.8, 1.0), the sensitivity was
low (0.5; 95% CI: 0.3, 0.7), indicating
that FMS composite scores less than or
equal to 14 may suggest higher injury risk
but FMS composite scores greater than
14 do not rule out future injury risk. In a
separate study on a group of Marines, a
composite score less than or equal to 14
on the FMS demonstrated limited ability to predict all future musculoskeletal
injuries (traumatic or overuse), with a
sensitivity of 0.45 and specificity of 0.71,
while the same cutoff value was able to
predict a serious injury (any injury that
was severe enough to remove the participant from the training program) with
a sensitivity of 0.12 and a specificity of
0.94.21 The FMS was also able to predict
injury risk in female collegiate athletes.2
Finally, in another study, firefighters with
a previous history of injury demonstrated
lower FMS composite scores.23 However,
it is not clear for which sports or professions the FMS is optimal in predicting
injury risk, what types of musculoskel-
FIGURE 1. Functional Movement Screen tests. (A) In-line lunge, (B) hurdle step, (C) deep squat, (D) quadruped
rotary stability, (E) active straight leg raise, (F) shoulder mobility, and (G) trunk stability push-up.
etal injuries are predicted by low FMS
composite scores, and whether the original cutoff score of less than or equal to 14
points on the FMS is valid in the different
populations.
Additionally, researchers have found
that FMS composite scores increased
in football players,13 firefighters,6 and
service members8 following corrective
exercises that addressed possible impairments associated with altered movement
patterns noted on the FMS component
tests. In a group of Marines, 80% of those
with a score less than or equal to 14 also
demonstrated lower fitness scores on a
standardized fitness test compared to
those who had an FMS composite score
greater than 14.21 However, Okada et al22
found that FMS composite scores were
not related to performance or core stability measures among healthy participants.
Interpretation of FMS scores is limited by the scant evidence16 regarding
the FMS's psychometric properties and,
in particular, the reliability of both composite and individual component scores.
An initial study by Minick et al16 found
acceptable levels of interrater agreement
on the FMS component scores among
novice and expert raters in a sample of
active college-age participants (to include college varsity athletes). However,
this study had several limitations: (1) it
did not assess test-retest reliability, (2)
all raters assessed the same movement
pattern via videotaped analysis, and (3)
it only assessed agreement of individual
FMS component scores and did not assess the overall FMS composite score,
which is typically used as the primary
indicator of injury risk. Traditionally,
the FMS is assessed in real time, without the benefit of video playback. Variability of human movement across trials
theoretically should exist; therefore, testretest analysis could lower the reported
agreement values. Additionally, the FMS
is often assessed in a group setting (eg,
preseason physical or preparticipation
screening), requiring the use of multiple
raters, who may or may not be the same
raters to assess the movement at followup testing. Therefore, a more robust reliability study is required to enhance the
understanding of the psychometric properties of the FMS.
Although these initial FMS studies,
which established the validity of the FMS
journal of orthopaedic & sports physical therapy | volume 42 | number 6 | june 2012 | 531
42-06 Teyhen.indd 531
5/22/2012 5:38:57 PM
[
for predicting musculoskeletal conditions
and injuries and the response to training,
are encouraging, their data are preliminary and not published in widely accessible journals. Exploring the psychometric
properties of the FMS in a large active
population would enhance the generalizability of the previous findings beyond
a limited subgroup of professional and
collegiate athletes and students. The
primary purpose of this study was to determine the intrarater (test-retest) and
interrater reliability of the FMS component and composite scores in young,
healthy service members, when tested by
a counterbalance group of novice raters
in real time. Specifically, agreement was
assessed on the FMS component scores,
whereas reliability, response stability, and
error threshold measurements were obtained for the FMS composite scores. A
secondary purpose of this study was to
describe the FMS component and composite scores in this population.
METHODS
research report
TABLE 1
]
Demographics
Type
Mean  SD
95% CI
Age, y
25.2  3.8
24.3, 26.2
Height, cm
175.5  9.6
173.1, 177.9
Weight, kg
77.5  12.5
74.4, 80.7
Body mass index, kg/m2
25.1  3.1
24.3, 25.9
Abbreviation: CI, confidence interval.
TABLE 2
FMS Descriptive Analysis*
FMS Component Score
Test
0
1
2
3
Mean  SD
Trunk stability push-up
0
7
29
27
2.3  0.7
Quadruped rotary stability
0
3
56
5
2.0  0.3
Shoulder mobility
0
2
19
43
2.6  0.6
Active straight leg raise
0
1
36
27
2.4  0.5
Deep squat
0
3
42
19
2.3  0.5
Hurdle step
0
1
51
12
2.2  0.4
In-line lunge
0
1
29
33
2.5  0.5
Abbreviation: FMS, Functional Movement Screen.
*The data displayed represent the first analysis of rater 1 on the first day of data collection (n = 64).
Participants
T
he convenience sample included
participants who were recruited
over an 8-week period from service
members in training at Fort Sam Houston, TX. Potential participants were
provided a briefing about the study and
were given the opportunity to volunteer.
Participants were eligible for inclusion if
they were between the ages of 18 and 35
years or emancipated minors (17-yearolds who are considered adults and allowed to join the armed services), fluent
in English, and had no current or previous complaint of lower extremity pain,
spine pain, or medical or neuromusculoskeletal disorders that limited participation in work or exercise in the last 6
months. Participants were excluded if
they were currently seeking medical care
for lower extremity injuries or had previous medical history that included any
surgery for lower extremity injuries. Participants were also excluded if they were
unable to participate in physical training
due to other musculoskeletal injuries;
had a history of fracture (stress or traumatic) in the femur, pelvis, tibia, fibula,
talus, or calcaneus; or were known to be
pregnant.
Potential participants were provided
an overview of the research study and
specific details of the entrance criteria.
After the presentation was completed,
those who met the entrance criteria were
asked to squat and then hop unilaterally
on each leg in the group setting. Individuals who met the entrance criteria and
did not have pain on the squat and hop
tests were informed about upcoming data
collection dates. Those individuals who
opted to volunteer returned the following week to sign informed consent forms
and were enrolled in the study. Within
the military training environment, these
procedures allowed potential participants the option to not return if they
were not interested in volunteering in the
study, and were designed to minimize any
potential perception of coercion. All participants signed consent forms approved
by the Brooke Army Medical Center Institutional Review Board.
Examiners
The novice examiners participating in
this study consisted of 8 physical therapy
students enrolled in their second and
third semesters of a doctor of physical
therapy training program prior to their
1-year clinical internship. Before testing,
all examiners underwent 20 hours of
FMS training led by 4 physical therapists
and 1 research assistant. Four physical
therapy students were randomly assigned to the participants to assess intrarater test-retest reliability by assessing
the FMS on day 1 and day 2. The goal
of randomly selecting a rater to perform
the intrarater test-retest reliability was
to increase the variability in the study
design. Each rater used for the intrarater
test-retest reliability measured between
532 | june 2012 | volume 42 | number 6 | journal of orthopaedic & sports physical therapy
42-06 Teyhen.indd 532
5/22/2012 5:38:58 PM
14 and 18 participants. There were no
differences in outcomes across raters, so
aggregate data were analyzed.
A second set of 4 physical therapy students were randomly assigned to view the
participants’ movement simultaneously
with the first set of raters for the interrater reliability assessment on day 2. To
minimize bias, raters were randomly assigned, raters for day 2 were blinded to
day 1 raters’ measurements, pairs of raters on day 2 were blinded to each other's
analysis and scoring, and 48 to 72 hours
of time elapsed between intrarater testretest reliability measurements. The goal
of having a random set of 2 raters assess
each participant was to increase the variability in the study design to more closely
mimic field conditions, which often include mass screenings that utilize multiple raters.
Procedures
The FMS is composed of 7 component
tests used to assess different fundamental
movement patterns.3-5 Participants completed the component tests in a counterbalanced order, including the deep
squat, hurdle step, in-line lunge, shoulder
mobility, active straight leg raise, trunk
stability push-up, and quadruped rotary
stability tests (FIGURE 1). Five of 7 component tests assess asymmetry by measuring
the test bilaterally. If discrepancies exist
between the left and right sides, asymmetry is noted for that component test and
the lower of the 2 scores is included in the
FMS composite score. In addition to the
7 component tests, the FMS includes 3
clearing tests that assess for pain: shoulder internal rotation and abduction with
the hand placed on the opposite shoulder,
lumbar extension performed in the prone
press-up position, and end-range lumbar
flexion in quadruped. Pain on a clearing
test resulted in a score of 0 for the shoulder mobility, trunk stability push-up, or
rotary stability test, respectively. Participants performed all tests without a preparticipation warm-up.
Each component test was scored on
an ordinal scale (0 to 3 points), based
on the quality of movement, with 3 being the maximum score.3-5 A score of 2
indicated that the participant required
some type of compensation or was unable to complete the entire movement. A
score of 1 was given if the individual was
unable to remain in the movement position throughout the movement, lost balance during the test, or did not meet the
minimum criteria to score a 2. Pain during any of the FMS component tests or
during any of the clearing tests indicated
a score of 0. All participants were allowed
to perform each component test up to 3
times, and the maximal score achieved
was recorded. The scores of the component tests were summed, resulting in a
composite score from 0 to 21 points, with
21 being the maximum composite score.
Additional details on scoring of each of
the component tests and the composite
score are provided elsewhere3-5 and in the
APPENDIX.
Statistical Analysis
Descriptive statistics and frequency
counts were calculated. Agreement of
the component tests was analyzed with
a weighted kappa statistic. The weighted
kappa scores were as follows: 80% and
higher, excellent agreement; from 60%
to 79.9%, substantial levels of agreement;
from 40% to 59.9%, moderate agreement; and below 40%, poor to fair agreement.24 Reliability of the composite test
scores was analyzed using intraclass correlation coefficients (ICCs). ICC values of
0.75 and above represent good reliability,
those between 0.50 and 0.74 represent
moderate reliability, and those below
0.50 indicate poor reliability.24 Intrarater
test-retest reliability was assessed using
an ICC3,1 model, while interrater reliability was assessed using an ICC2,1 model.
Response stability of the intrarater and
interrater reliability of the composite
scores was calculated using the standard
error of the measurement (SEM) at the
95% level of confidence. The minimal
detectable change (MDC95) values at the
95% level of confidence were calculated
to determine error thresholds. Statistical
analyses were conducted using SPSS Version 17.0 (SPSS Inc, Chicago, IL).
RESULTS
S
ixty-four participants (53
males, 11 females) met the inclusion
and exclusion criteria and completed the study (TABLE 1). The mean  SD
age of the participants was 25.2  3.8
years and their body mass index was 25.1
 3.1 kg/m2. Overall, the participants included routine exercisers who endorsed
a statement that they exercised a minimum of 4 days per week (n = 54, 78.2%).
Although the participants were attending
training for their military occupation, the
majority of the participants were routine
exercisers for more than 3 years. Specifically, 29 (45.3%) participants reported
performing routine exercise for more
than 5 years, 21 (32.8%) for 3 to 5 years,
9 (14.1%) for 1 to 3 years, and 5 (7.8%) for
less than 1 year. Descriptive statistics on
FMS performance are provided in TABLE 2.
None of the participants had pain on the
3 FMS clearing tests. Interrater reliability
was calculated on 63 participants, based
on an illness of 1 of the raters on day 2 of
testing. Only 15.6% (n = 10) of the participants were identified to be at risk for
injury, based on an FMS composite score
of less than or equal to 14 points.
Agreement of the 7 component tests
of the FMS (scored 0 to 3) demonstrated
moderate to excellent interrater agreement (TABLE 3). Specifically, the novice
raters demonstrated excellent interrater
agreement on the trunk stability pushup; substantial interrater agreement
on the quadruped rotary stability, deep
squat, active straight leg raise, hurdle
step, and shoulder mobility component
tests; and moderate interrater agreement
on the in-line lunge. Intrarater (test-retest) agreement scores at 48 to 72 hours
demonstrated substantial agreement on
the trunk stability push-up, shoulder mobility, active straight leg raise, deep squat,
and in-line lunge component tests; moderate agreement on the hurdle step; and
poor agreement on the quadruped rotary
journal of orthopaedic & sports physical therapy | volume 42 | number 6 | june 2012 | 533
42-06 Teyhen.indd 533
5/22/2012 5:38:59 PM
[
TABLE 3
research report
Agreement of FMS Component Scores (0-3 points)
Percent Agreement
κw
95% CI
Trunk stability push-up
78
0.82
0.73, 0.90
Quadruped rotary stability
92
0.77
0.57, 0.96
Shoulder mobility
86
0.73
0.57, 0.89
Active straight leg raise
84
0.69
0.51, 0.87
Deep squat
83
0.68
0.51, 0.85
Hurdle step
88
0.67
0.45, 0.88
In-line lunge
68
0.45
0.25, 0.65
Trunk stability push-up
68
0.68
0.55, 0.81
Quadruped rotary stability
83
0.29
0.05, 0.50
Shoulder mobility
81
0.68
0.53, 0.80
Active straight leg raise
80
0.60
0.42, 0.74
Deep squat
88
0.76
0.63, 0.85
Hurdle step
86
0.59
0.42, 0.73
In-line lunge
83
0.69
0.48, 0.77
Type/Test
Interrater
Intrarater
Abbreviations: CI, confidence interval; FMS, Functional Movement Screen.
TABLE 4
Reliability of FMS Composite Scores (0-21 points)
Type
ICC
95% CI
SEM
MDC95
Interrater
0.76
0.63, 0.85
0.92
2.54
Intrarater (test-retest)
0.74
0.60, 0.83
0.98
2.07
Abbreviations: CI, confidence interval; FMS, Functional Movement Screen; ICC, intraclass correlation
coefficient; MDC95, minimal detectable change at the 95% level of confidence; SEM, standard error of
measurement.
stability component test.
The interrater reliability (same day)
of the FMS composite score (scored
0-21) resulted in an ICC2,1 of 0.76 (95%
CI: 0.63, 0.85) and was considered good
(TABLE 4). The SEM for interrater reliability of the composite test was 0.92 points,
and the MDC95 was 2.54 points on the
21-point scale. Visual representation of
the FMS composite scores between raters is provided in FIGURE 2. The intrarater
reliability (test-retest at 48 to 72 hours)
of the FMS composite scores resulted in
an ICC3,1 of 0.74 (95% CI: 0.60, 0.83) and
was considered to be moderate (TABLE 4).
Visual representation of the intrarater
test-retest FMS composite scores is provided in FIGURE 3. The SEM for intrarater
test-retest reliability was 0.98 points and
the MDC95 was 2.07 points.
DISCUSSION
T
he FMS has an adequate level of
reliability when assessed in healthy
service members by novice raters.
The interrater agreement of the FMS
component scores ranged from moderate to excellent, with 6 of the 7 tests categorized as having substantial agreement
(κw60%). The intrarater and interrater
point estimates of the FMS composite
score reliability ranged from 0.74 to 0.76,
with the 95% CIs suggestive of moderate
to good reliability. The SEMs for both
interrater and intrarater reliability were
]
less than 1 point, while the MDC95 ranged
from 2.1 to 2.5 points on the 21-point
scale. The SEM and MDC values were
similar for both intrarater reliability that
repeated the assessment of the movement
patterns over a 48-to-72–hour period and
interrater reliability that had 2 raters assess the same movement pattern simultaneously. Therefore, one can expect
the error of measurement to be within 1
point across raters and across time, while
a minimum improvement between 2 and
3 points on the 21-point scale would be
required to demonstrate a real change
over time.
These results are consistent with a
prior publication on FMS reliability.
Minick et al16 reported substantial to excellent interrater agreement on individual FMS component scores when using
2 novice and 2 expert raters assessing
videotape performance of active collegeage students and varsity athletes. Adding to the literature, our study provides
detailed information on the intrarater
and interrater reliability of both FMS
component and composite scores by
randomly assigned novice raters. Specifically, our study utilized 8 entry-level
physical therapy students as raters to
collect data prior to their clinical internship. Additionally, these raters measured
all movements in real time, without the
benefit of being able to replay a videotape (the methodology used by Minick et
al16). The increased number of raters and
real-time analysis of movement in multiple participants in our study mimic a
preparticipation screening environment,
thus enhance the generalizability of the
results. Further research is needed to assess the stability of the FMS scores over
longer periods. Ultimately, the reliability
of this group of novice raters was comparable to previously published research
and provides further support for the FMS
as a reliable tool to screen in a relatively
diverse, noncollegiate but physically active population.16
Only 15.6% (n = 10) of the participants in this study had an FMS composite score less than or equal to 14 points.
534 | june 2012 | volume 42 | number 6 | journal of orthopaedic & sports physical therapy
42-06 Teyhen.indd 534
5/22/2012 5:39:00 PM
Rater 2
Rater 1
12
13
14
15
16
17
18
19
Total
12
2
1
1
0
0
0
0
0
4
13
1
0
1
0
0
0
0
0
2
14
1
2
1
0
0
0
0
0
4
15
0
0
3
4
3
0
0
0
10
16
0
1
4
1
6
1
0
0
13
17
0
0
1
3
3
2
3
2
14
18
0
0
0
1
1
6
4
0
12
19
0
0
0
0
0
1
1
1
3
20
0
0
0
0
0
0
0
1
1
Total
4
4
11
9
13
10
8
4
63
FIGURE 2. Comparison of Functional Movement Screen composite scores between rater 1 and rater 2. Green boxes
indicate agreement (n = 20), yellow boxes indicate a composite-score difference of only 1 point (n = 27), and
orange boxes indicate a composite-score difference of 2 to 3 points (n = 16).
FMS Day 2 Composite Score
FMS Day 1 Composite Score
Although this may not seem surprising,
given that the participants were relatively healthy, it supports the suggestion by
Cook et al3,4 that FMS scores can identify
altered movement patterns in generally
healthy and pain-free participants. Our
results are similar to those published by
O’Connor et al,21 who found that 10% of
the 874 Marine officer candidates scored
less than or equal to 14 points on the
FMS. If the initial research that identified
the cutoff value were validated, it would
suggest that the FMS would be capable
of identifying a subset of individuals at
increased risk for time-loss injury within
a population of young, healthy service
members. Based on the use of the FMS
for mass screenings (eg, preseason or annual physical examinations), an injury
prediction screening that could identify
only 15.6% of the population as having
a high injury risk would allow the associated medical staff to prioritize the allocation of limited resources toward the
development of individualized injury
prevention interventions (eg, corrective
exercise prescriptions) for this group.
However, the validity of the 14-point cutoff score for this sample cannot be verified
in this study, because longitudinal followup was not performed to assess actual injury rates. Based on the SEM of 1 point
and the MDC95 value between 2.1 and 2.5
points, it would be more conservative to
use a cutoff score of 15 (based on SEM) or
16 to 17 (based on MDC95) to determine
those who may benefit from corrective
exercise prescription to help mitigate injury risk, until the validity of the 14-point
cutoff value can be determined.
One of the limitations noted in the
FMS component tests was a restriction
in the range of scores. Specifically, based
on our inclusion/exclusion criteria, no
participants scored a 0 on any of the
FMS component tests, and only 18 of the
446 scored movement patterns resulted
in a score of 1; the remaining movement
patterns either received a score of 2 or
3. This restriction in range might have
reduced the reliability estimates of the
FMS component scores. For example,
12
13
14
15
16
17
18
19
Total
10
1
0
0
0
0
0
0
0
1
11
0
0
0
0
0
0
0
0
0
12
1
1
1
0
0
0
0
0
3
13
2
1
1
1
0
0
0
0
5
14
0
1
1
1
2
1
0
0
6
15
0
1
2
5
3
1
0
0
12
16
0
0
5
0
4
3
1
0
13
17
0
0
0
2
4
1
2
0
9
18
0
0
1
0
1
2
4
4
12
19
0
0
0
0
0
2
0
0
2
20
0
0
0
0
0
0
1
0
1
Total
4
4
11
9
14
10
8
4
64
FIGURE 3. Comparison of FMS composite scores for rater 1 (day 1 to day 2). Green boxes indicate agreement (n =
17), yellow boxes indicate a composite-score difference of only 1 point (n = 26), orange boxes indicate a compositescore difference of 2 to 3 points (n = 20), and the red box indicates a composite-score difference greater than 3
points (n = 1). Abbreviation: FMS, Functional Movement Screen.
the in-line lunge was determined to have
a weighted kappa of 0.45; for this test, no
movements were scored as a 0 or 1. Additionally, only 11 of the 63 paired ratings
had a disagreement, with 25 agreements
for a score of 2 and 27 agreements for a
score of 3. Compared to the other FMS
component scores, the in-line lunge and
the quadruped rotary stability had the
biggest discrepancy between the percent
agreement (68% and 83%, respectively)
and weighted kappa (0.45 and 0.29, re-
journal of orthopaedic & sports physical therapy | volume 42 | number 6 | june 2012 | 535
42-06 Teyhen.indd 535
5/22/2012 7:42:05 PM
[
spectively). Interestingly, the lowest levels
of agreement between novice raters for
both our study and Minick et al16 involved
the in-line lunge and quadruped rotary
stability tests. Difficulty in performing
the quadruped rotary stability test (only
5 of the 64 participants obtained a score
of 3 on day 1) also limited variability and
potentially intrarater agreement of this
measure. Although the restricted range
might have influenced statistical calculations, it is important to point out that rater experience and lack of clearly defined
scoring criteria, especially mid-range
performance, may have also influenced
results for these select measures. Future
research should determine whether better criteria may help to differentiate levels
of performance on the quadruped rotary
stability test or to determine the influence of removing the quadruped rotary
stability test on the predictive validity of
the FMS composite score.
Future study designs should assess the
reliability of the FMS using novice raters
and participants with varying activity
levels and sport-specific requirements.
Additional longitudinal studies are also
required to establish the predictive validity and optimal cut score for various
populations. This level of critical investigation would help to enhance the external
validity of the FMS and to substantiate its
use in the general clinical population, as
well as in specific sports settings. Future
research should also determine whether
there is a ceiling effect in the ability of the
FMS to detect change over time. Based
on the MDC95 of 2.1 to 2.5 points, positive change may not be able to be noted
for individuals who score greater than
18 points at baseline testing. Different
scoring criteria or cutoff values may be
needed to better differentiate high-end
performance on the FMS.
CONCLUSIONS
A
mong novice raters, the FMS
composite score demonstrated
moderate to good interrater and
intrarater reliability, and acceptable lev-
research report
els of measurement error. The measures
of reliability and measurement error were
similar for both intrarater reliability that
repeated the assessment of the movement patterns over a 48-to-72–hour period and interrater reliability that had 2
raters assess the same movement pattern
simultaneously. The interrater agreement
of the FMS component scores was good
to excellent for the push-up, quadruped, shoulder mobility, straight leg raise,
squat, hurdle, and lunge. Only 15.6% (n
= 10) of the participants were identified
as being at risk for injury based on previously published cutoff values. t
]
Warren, and First Lieutenant Sam Wood.
Illustrations for the APPENDIX were provided by
Elizabeth Holder.
KEY POINTS
FINDINGS: When using novice raters, the
FMS composite scores had moderate to
good reliability (ICC = 0.74 and 0.76;
SEM, 1.0 points; MDC95, 2.1 and 2.5
points) and the FMS component scores
ranged from moderate to excellent
agreement (κw = 0.29-0.82).
IMPLICATIONS: The FMS has adequate reliability when assessed in young, healthy
service members by novice raters over a
48-to-72–hour period.
CAUTION: Reliability data must be interpreted within the context of the sample
tested and the methods used (ie, time
between testing for test-retest reliability
estimates).
ACKNOWLEDGEMENTS: This study was done in
collaboration with research assistants from
the University of Texas Health Science Center,
Physical Therapy Department, San Antonio,
TX: Mark Bauernfeind, Francis Bisagni, Jordan Boldt, Cindy Boyer, Cara Dobbertin, Steve
Elliot, Angela Gass, Germaine Herman, Lacey
Jung, Jake Mitchess, Teddy Ortiz, Kelly Rabon,
Jason Smith, Megan Swint, Joshua Trock, and
Jerry Yeung. Additional research assistants
from US Army-Baylor University, Department of Physical Therapy, US Army Medical
Department Center and School, San Antonio, TX: First Lieutenant Moshe Greenberg,
Captain Sarah Hill, First Lieutenant Crystal Straseske, First Lieutenant Sarah Villena,
First Lieutenant Christina Yost, First Lieutenant Kristen Zosel, First Lieutenant Rick
REFERENCES
1. A
lmeida SA, Williams KM, Shaffer RA, Brodine
SK. Epidemiological patterns of musculoskeletal
injuries and physical training. Med Sci Sports
Exerc. 1999;31:1176-1182.
2. Chorba RS, Chorba DJ, Bouillon LE, Overmyer
CA, Landis JA. Use of a functional movement
screening tool to determine injury risk in female
collegiate athletes. N Am J Sports Phys Ther.
2010;5:47-54.
3. Cook G, Burton L, Hoogenboom B. Pre-participation screening: the use of fundamental movements as an assessment of function - part 1. N
Am J Sports Phys Ther. 2006;1:62-72.
4. Cook G, Burton L, Hoogenboom B. Pre-participation screening: the use of fundamental movements as an assessment of function - part 2. N
Am J Sports Phys Ther. 2006;1:132-139.
5. Cook G, Burton L, Kiesel K, Rose G, Bryant MF.
Movement: Functional Movement Systems:
Screening—Assessment—Corrective Strategies.
Aptos, CA: On Target Publications; 2010.
6. Cowen VS. Functional fitness improvements
after a worksite-based yoga initiative. J Bodyw
Mov Ther. 2010;14:50-54. http://dx.doi.
org/10.1016/j.jbmt.2009.02.006
7. Emery CA, Rose MS, McAllister JR, Meeuwisse
WH. A prevention strategy to reduce the incidence of injury in high school basketball: a
cluster randomized controlled trial. Clin J Sport
Med. 2007;17:17-24. http://dx.doi.org/10.1097/
JSM.0b013e31802e9c05
8. Goss DL, Christopher GE, Faulk RT, Moore J.
Functional training program bridges rehabilitation and return to duty. J Spec Oper Med.
2009;9:29-48.
9. Hale SA, Hertel J, Olmsted-Kramer LC. The effect of a 4-week comprehensive rehabilitation
program on postural control and lower extremity
function in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2007;37:303311. http://dx.doi.org/10.2519/jospt.2007.2322
10. Holm I, Fosdahl MA, Friis A, Risberg MA, Myklebust G, Steen H. Effect of neuromuscular training on proprioception, balance, muscle strength,
and lower limb function in female team handball
players. Clin J Sport Med. 2004;14:88-94.
11. Jones BH, Cowan DN, Tomlinson JP, Robinson
JR, Polly DW, Frykman PN. Epidemiology of
injuries associated with physical training among
young men in the army. Med Sci Sports Exerc.
1993;25:197-203.
12. Jones BH, Knapik JJ. Physical training and
exercise-related injuries. Surveillance, research
and injury prevention in military populations.
Sports Med. 1999;27:111-125.
13. Kiesel K, Plisky P, Butler R. Functional move-
536 | june 2012 | volume 42 | number 6 | journal of orthopaedic & sports physical therapy
42-06 Teyhen.indd 536
5/22/2012 5:39:02 PM
14.
15.
16.
17.
ment test scores improve following a standardized off-season intervention program in
professional football players. Scand J Med
Sci Sports. 2011;21:287-292. http://dx.doi.
org/10.1111/j.1600-0838.2009.01038.x
Kiesel K, Plisky PJ, Voight ML. Can serious
injury in professional football be predicted by a
preseason functional movement screen? N Am J
Sports Phys Ther. 2007;2:147-158.
Mandelbaum BR, Silvers HJ, Watanabe DS,
et al. Effectiveness of a neuromuscular and
proprioceptive training program in preventing anterior cruciate ligament injuries in
female athletes: 2-year follow-up. Am J Sports
Med. 2005;33:1003-1010. http://dx.doi.
org/10.1177/0363546504272261
Minick KI, Kiesel KB, Burton L, Taylor A, Plisky
P, Butler RJ. Interrater reliability of the functional movement screen. J Strength Cond Res.
2010;24:479-486. http://dx.doi.org/10.1519/
JSC.0b013e3181c09c04
Myer GD, Ford KR, Brent JL, Hewett TE. The
effects of plyometric vs. dynamic stabilization
18.
19.
20.
21.
and balance training on power, balance, and
landing force in female athletes. J Strength
Cond Res. 2006;20:345-353. http://dx.doi.
org/10.1519/R-17955.1
Myer GD, Ford KR, McLean SG, Hewett TE. The
effects of plyometric versus dynamic stabilization and balance training on lower extremity biomechanics. Am J Sports Med. 2006;34:445-455.
http://dx.doi.org/10.1177/0363546505281241
Myer GD, Ford KR, Palumbo JP, Hewett TE.
Neuromuscular training improves performance
and lower-extremity biomechanics in female
athletes. J Strength Cond Res. 2005;19:51-60.
http://dx.doi.org/10.1519/13643.1
National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
CDC Injury Research Agenda. Atlanta, GA: US
Department of Health and Human Services;
2002.
O’Connor FG, Deuster PA, Davis J, Pappas CG,
Knapik JJ. Functional movement screening:
predicting injuries in officer candidates. Med Sci
Sports Exerc. 2011;43:2224-2230. http://dx.doi.
org/10.1249/MSS.0b013e318223522d
22. O
kada T, Huxel KC, Nesser TW. Relationship
between core stability, functional movement,
and performance. J Strength Cond Res.
2011;25:252-261. http://dx.doi.org/10.1519/
JSC.0b013e3181b22b3e
23. Peate WF, Bates G, Lunda K, Francis S,
Bellamy K. Core strength: a new model
for injury prediction and prevention. J Occup Med Toxicol. 2007;2:3. http://dx.doi.
org/10.1186/1745-6673-2-3
24. Portney LG, Watkins MP. Foundations of Clinical
Research: Applications to Practice. 2nd ed. Upper Saddle River, NJ: Prentice Hall; 2000.
25. van Mechelen W. Running injuries. A review
of the epidemiological literature. Sports Med.
1992;14:320-335.
@
MORE INFORMATION
WWW.JOSPT.ORG
APPENDIX
FUNCTIONAL MOVEMENT SCREEN
Score
Criteria
Illustration
Deep Squat
3
2
1
0
• Upper torso is parallel with tibia or toward vertical
• Femur below horizontal
• Knees are aligned over feet
• Dowel aligned over feet
Performed with heels on 2 × 6-in board
• Upper torso is parallel with tibia or toward vertical
• Femur below horizontal
• Knees are aligned over feet
• Dowel aligned over feet
Performed with heels on 2 × 6-in board
• If any of the 4 criteria are not met when the squat is performed with
heels on 2 × 6-in board, the score is 1
• Pain during test
journal of orthopaedic & sports physical therapy | volume 42 | number 6 | june 2012 | 537
42-06 Teyhen.indd 537
5/22/2012 5:39:03 PM
[
research report
]
APPENDIX
Score
3
2
1
0
3
2
1
0
3
Criteria
•
•
•
•
•
•
•
•
•
Hurdle Step (test both right and left sides)*
Foot clears cord (does not touch) and remains dorsiflexed as leg is
lifted over hurdle
Hips, knees, and ankles remain aligned in the sagittal plane
Minimal to no movement is noted in lumbar spine
Dowel and hurdle remain parallel
Alignment is lost between hips, knees, and ankles
Movement is noted in lumbar spine
Dowel and hurdle do not remain parallel
Contact between foot and hurdle
Loss of balance is noted
Pain during test
•
•
•
•
•
•
•
•
•
•
•
•
•
In-line Lunge (test both right and left sides)*
nee touches board behind heel
K
Dowel and feet remain in sagittal plane
Dowel contacts remain (head, thoracic spine, sacrum)
Dowel remains vertical, no torso movement noted
Knee does not touch behind heel
Dowel and feet do not remain in sagittal plane
Dowel contacts do not remain
Dowel remains vertical
Movement is noted in torso
Loss of balance is noted
Inability to achieve start position
Inability to touch knee to board
Pain during test
•
•
•
2
•
•
1
•
0
•
Illustration
Active Straight Leg Raise (test both right and left sides)*
Malleolus of tested lower extremity located in the region between
mid-thigh and anterior superior iliac spine of opposite lower extremity (green region)
Opposite hip remains neutral (hip does not externally rotate), toes
remain pointing up
Opposite knee remains in contact with board
Malleolus of tested lower extremity located in the region between
mid-thigh and knee joint line of opposite lower extremity (yellow
region) while other criteria are met
Malleolus of tested lower extremity located in the region below knee
joint line of opposite lower extremity (red region) while other criteria
are met
Pain during test
538 | june 2012 | volume 42 | number 6 | journal of orthopaedic & sports physical therapy
42-06 Teyhen.indd 538
5/22/2012 5:39:05 PM
APPENDIX
Score
Criteria
3
2
1
0
Shoulder Mobility (test both right and left sides)*
• Fists are within 1 hand length
• Fists are within 1.5 hand lengths
• Fists are not within 1.5 hand lengths
• Pain during test
Shoulder mobility clearing test: if pain is noted as elbow is lifted,
shoulder mobility is scored as 0
3
2
1
0
Illustration
Trunk Stability Push-up
• P
erform 1 repetition; the thumbs are aligned with forehead for males
and chin for females
• Body is lifted as 1 unit (no sag in lumbar spine)
• Perform 1 repetition; the thumbs are aligned with chin for males and
clavicle for females
• Body is lifted as 1 unit (no sag in lumbar spine)
• Unable to perform 1 repetition with thumbs aligned with chin for
males and clavicle for females
• Pain during test
Extension clearing test: if pain is noted during a prone press-up, pushup is scored as 0
journal of orthopaedic & sports physical therapy | volume 42 | number 6 | june 2012 | 539
42-06 Teyhen.indd 539
5/22/2012 5:39:06 PM
[
research report
]
APPENDIX
Score
3
2
1
0
Criteria
Illustration
Quadruped Rotary Stability (test both right and left sides)*
• 1 unilateral repetition (lift arm and leg from same side of body)
• Keep spine parallel to board
• Knee and elbow touch in line over the board and then return to the
start position
• 1 diagonal repetition (lift arm and leg from opposite sides of body)
• Keep spine parallel to board
• Knee and elbow touch in line over the board and then return to the
start position
• Inability to perform diagonal repetition
• Pain during test
Flexion clearing test: if pain is noted during quadruped flexion, rotary
stability is scored as 0
*For component tests that are scored for both the right and left sides, the lower score is used when calculating the Functional Movement Screen
composite score.
GO GREEN By Opting Out of the Print Journal
JOSPT subscribers and APTA members of the Orthopaedic and Sports
Physical Therapy Sections can help the environment by “opting out” of
receiving the Journal in print each month as follows. If you are:
· A JOSPT subscriber: Email your request to jospt@jospt.org or call the
Journal office toll-free at 1-877-766-3450 and provide your name and
subscriber number.
· An APTA Orthopaedic or Sports Section member: Go to www.apta.org
and update your preferences in the My Profile area of myAPTA.
Select “myAPTA” from the horizontal navigation menu (you’ll be asked
to login, if you haven’t already done so), then proceed to “My Profile.”
Click on the “Email & Publications” tab, choose your “opt out”
preferences and save.
Subscribers and members alike will continue to have access to JOSPT
online and can retrieve current and archived issues anytime and anywhere
you have Internet access.
540 | june 2012 | volume 42 | number 6 | journal of orthopaedic & sports physical therapy
42-06 Teyhen.indd 540
5/22/2012 5:39:07 PM