Inter-tester Reliability Study
of the Functional Movement
TM
Screen (FMS )
Mariam Pashtoonwar, Anang Chokshi,
Lindsay Blaauw, Cesar Fajardo
Kaiser Permanente Sports and
Extremities Fellowship
Contents
•
•
•
•
Description of FMSTM
Evidence for FMSTM
Description of Testing Procedure
Inter-tester Reliability Results
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
Functional Movement Screen
(FMSTM)
7 Fundamental Movement Tests
1)
2)
3)
4)
5)
6)
7)
Deep Squat
Hurdle Step
In-line Lunge
Shoulder Mobility
Active Straight Leg Raise (SLR)
Trunk Stability Push Up
Rotary Stability
1.) Deep Squat
Instructions: Stand with feet shoulder width apart.
Hold the stick over your head with your shoulders in a
“V” position, elbows straight. Squat down as far as
you can and try to keep your heels on the floor with
your head and chest facing forward.
Grading:
III: Subject able to squat down with heels on
ground & chest/head facing forward. Arms directly
over ahead.
II: Proper form as stated above with 2x6 under
heels
I: If they cannot complete the movement properly
2.) Hurdle Step
•
*Can be performed up to 3 times bilaterally
The hurdle should be aligned with the height of the
subject’s tibial tuberosity.
Instructions: Place your feet together with your toes
aligned touching the base of the 2x6. Place the stick behind
your head across your shoulders and below your neck.
Slowly step over the hurdle with one leg and touch your
heel to the floor, making sure your standing leg stays
straight. Then return your moving leg to the starting position.
Repeat with the other leg.
Grading:
III: Subject able to complete bilaterally with no twisting or
compensatory movement
II: Subject compensated in some way by twisting, leaning or
moving the spine
I:
Subject has loss of balance or if contact is made with the
hurdle.
3.) In-Line Lunge
*Can be performed up to 3 times bilaterally
Measure subject’s tibia length (from floor to the tibial tuberosity (in
centimeters)). A 2x6 board is placed on the floor. Using the tibia length a
mark is made on the board from the end of the subjects toes.
Instructions: Place your left heel on the end of the board. Hold the stick
behind your back with your left hand behind your neck and your right hand at
your tailbone. Keep the stick in contact with your head, mid-back and
tailbone to keep your back straight. Step forward with your right foot placing
your heel at the indicated mark. Bend both knees until your back
knee touches the board. Return to starting position. Repeat with opposite leg
and opposite hand holds
Grading:
III: Subject able to complete bilaterally with no twisting or
compensatory movement
II: Subject compensated in some way by twisting, leaning or
moving the spine
I:
Subject has loss of balance or unable to complete
4.) Shoulder Mobility
the
The subject’s hand will first be measured (in centimeters) from
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.
the
Instructions for the clearing exam: Place one hand on the
opposite shoulder and point your elbow upward. Repeat with
other hand. Ask “Any pain?”
Grading:
III: Subject’s fists are within one hand length
II: Subject’s fists are within 1 ½ hand lengths
I:
Subject’s fists fall outside this length.
Zero: Pain with clearing test (done at end of the test)
5.) Active Straight Leg Raise
*Can be performed up to 3 times bilaterally
Place a 2x6 board on the floor. (Place a dowel
perpendicular at the midpoint of the ASIS and the midpoint
of the patella at the thigh.)
Instructions: Lie on your back with your head flat and your arms
straight with your palms up and the back of your knees on the board. Lift
your leg with your ankle flexed and your knee straight and keep your
other knee in touching the board. Repeat with the other leg.
Grading:
III: If subject’s malleolus of the raised leg is located past the dowel
If malleolus does not pass the dowel then the dowel is aligned
along the medial malleolus of the test leg, perpendicular to the
floor.
II: If this point is between the thigh midpoint and the patella
I:
If this point is below the knee
6.) Trunk Stability Push Up
Instructions: Begin in a push-up position with your feet together
For a male: Place your hands down on the floor, shoulder width
apart with your thumbs at forehead height
For a female: Place your hands down on the floor, shoulder width
apart with your thumbs in line with your chin.
With your knees straight and on your toes, perform one push-up
while keeping your back straight.
Clearing Test Instructions: Begin face-down on the floor propped
on your elbows. Press up onto your hands extending your back.
Grading:
III: Complete one (1) pushup without lumbar spine lag
If the push up cannot be performed the hands are lowered with
the thumbs aligning with the chin for males and the clavicles
for females
II: Complete one (1) pushup with lumbar spine lag at modified
hand position
I:
Subject is unable to complete the test
Zero: Pain with clearing test (done at end of the test)
7.) Rotary Stability
*Can be performed up to 3 times bilaterally
Instructions: Begin on your hands and knees with your hands in line
with your shoulders and your knees in line with your hips. (PT
places a 2x6 board between their hands and knees so they are
in contact with the board). Reach forward with your right arm and
at the same time straighten out your right leg behind you only about
6 inches off the floor. Keep your arm and leg aligned with the
board. Then bring the leg and arm together until the elbow and knee
touch. Repeat with the other arm and leg.
If the subject cannot perform the movement above:
Tell them to “Do the same movement using opposite arm and leg.
For example, right elbow to the left knee while keeping your back
straight.
Grading:
III: Hand and knee remain in line with the 2x6 as well as the torso
and they complete the movement with same side arm and leg.
II: Hand and knee remain in line with the 2x6 as well as the torso
and they complete the movement with the opposite arm and leg.
I:
If loss of balance occurs or they cannot perform either
movements bilaterally.
EBP: Can Serious Injury In
Professional Football Be Predicted
By A Preseason Functional
Movement Screen? (NAJSPT
August 2007)
Kyle Kiesel, PT, PhD, ATC, CSCS
Philip J. Plisky, PT, DSc, OCS, ATC
Michael L. Voight, PT, DHSc, OCS, SCS
Purpose of Study
• To examine the relationship between the
relationship between professional football
players’ score on the FMSTM and the
likelihood of a player suffering a serious
injury over the course of one competitive
season.
Materials and Methods
•
•
•
•
Retrospective Study
N=45 professional football players
All players tested on FMSTM
Surveillance time for study: one full
football season (4.5 months)
Results of Data
• Cut off score that maximized specificity
and sensitivity of receiver-operated
characteristic (ROC) was 14
• Specificity = .91
• Sensitivity = .54
• Odds Ratio = 11.67
• Negative likelihood ratio = .51
Conclusion
• If a player scored < 14:
– 51% chance of suffering an injury
– Eleven fold increased chance of injury when
compared to players who had a higher score
Purpose of Current Study
• There is some evidence that shows the
FMS is useful to predict serious injury in
football players
• Question: What is the Inter-tester
Reliability of the Functional Movement
Screen?
Testing Procedure for Study
•
•
•
•
Subjects: High School Football Players
All subjects are Males aged 14-16
All players tested on FMSTM
Data gathered on: Age, Weight, Height,
Position, BMI, Previous Injury
Testing Procedure for Study
• One Physical Therapist administered test
• Instruction was given only by this one
therapist
• Three other physical therapists scored
each subject independently (Scorers A-C)
• Scores were not shared between
therapists during or post testing
Data Collection
• Scoring for the FMSTM based on procedure
delineated by Cook, Burton and
Hoogenboom1
• Each score was recorded for 7 individual
tests of FMSTM
Data Analysis Plan
• Total Number of Football Players Tested
N = 18
• Statistical Analysis Used:
– Kappa Coefficient
Kappa Coefficient
• Statistical measure of inter-rater
agreement
• Takes into account the agreement
occurring by chance
• Possible values range from +1 (perfect
agreement) to 0 (no agreement above that
expected by chance) to -1 (complete
disagreement)
Kappa’s Coefficient Cont’d…
• Kappa = (observed agreement - chance
agreement)/(1-chance agreement)
Kappa Strength
Kappa
Strength of Agreement
0.00
Poor
0.01-0.20
Slight
0.21-0.40
Fair
0.41-0.60
Moderate
0.61-0.80
Substantial
0.81-1.00
Almost Perfect
(from Landis and Koch, 1997)
Our Kappa Results
Average Kappa per Test:
1.) Deep Squat = 63%= Substantial
2.) Hurdle Step = 34%= Fair
3.) In-Line Lunge = 56%= Moderate
4.) Shoulder Mobility = 85%= Almost Perfect
5.) Active Straight Leg Raise = 77%= Substantial
6.) Trunk Stability Push Up = 81%= Almost Perfect
7.) Rotary Stability = 53%= Moderate
Observed agreement = 12/18 = 66.7%
A
0
B
1
2
0
1
III
IIII
7
2
II
IIIIII
8
3
3
III
5
10
3
3
Our Results Cont’d…
• Highest Inter-Rater Reliability for Shoulder
Mobility Test, Trunk Stability Push Up,
Active Straight Leg Raise and Deep Squat
• Inter-Rater Reliability lowest for Hurdle
Step
Discussion
• Higher Inter-Rater Reliability for shoulder
mobility and ASLR possibly due to more
objective measure, less variability
• Lower Inter-Rater Reliability for Hurdle Step, InLine Lunge and Rotary Stability secondary to
more subjective interpretation
• Variability in grading secondary to lack of
experience with the tests (i.e. increased
variability between Caesar’s scores vs. Mariam
and Anang’s)
Conclusion
• Overall, FMS is a reliable test: average of
all tests=moderate strength
• Ways to minimize difference in testers’
scores:
-all testers observe subject from same
place (i.e. frontal plane, sagittal, etc)
-testers should be equally trained
References
1. Cook G, Burton L, Hoogenboon B. Preparticipation screening: The use of
fundamental movements as an assessment of
function – Part 1. NAJSPT May 2006:1:62-71
2. 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 2:147-151