Chapter Objectives
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Explain the benefits of a functional, comprehensive movement screening process versus the traditional impairment-based evaluation approach.
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Differentiate between movement, testing, and assessment.
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Explain how poor movement patterns and dysfunctional movement strategies can result in injury or reinjury.
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Explain the use and components of the Functional Movement Screen and the Selective Functional Movement Assessment.
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Describe and score the movement patterns of the Functional Movement Screen and the Selective Functional Movement Assessment and interpret how the results from each can have an impact on clinical interventions.
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Articulate the difference between movement screening and specific functional performance tests.
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Apply specific functional performance test to clinical practice.
Introduction
Movement is at the core of the human journey. It is foundational to the human experience and allows us to interact with our environment in ways different from other mammals. Movement, which begins in the womb, is the basis of early growth and development. It proceeds in a highly predictable manner in infants and young children and is known as the developmental sequence or traditional motor development. When an individual reaches a certain age, full integration of reflexive behavior allows the development of purposive, highly developed, and unique mature motor programs. We continue to move functionally throughout a lifetime until the effects of aging alter the normalcy of movement.
Motion Versus Movement
Because movement is complex, it must be differentiated from the simpler construct of motion. The authors believe that many professionals lack a true understanding of movement; they err on the side of quantitative assessment of motion and fail to understand the hierarchic progression from general, fundamental movement patterns to specific, highly specialized movements. These highly specialized movements have complex, fine-tuned motor programs that support their consistency and intricacy. Most rehabilitation and medical professionals have been trained to measure isolated joint motion with goniometers, inclinometers, linear measurements, or ligament laxity tests. These types of motion assessment are not wrong, but rather represent only a piece of a much bigger puzzle of “movement” and the inherent stability and mobility demands that are part of the synchronous, elegant, coordinated activities that make up activities of daily living, work tasks, and sport maneuvers. Mere motion measurements cannot capture the whole spectrum of human movement, nor the complexity of human function.
Systems Approach to Movement
The premise of this chapter and the chapter that follows is that impairment-based, highly specialized motion assessment is far too limiting and in fact predisposes practitioners to errors in professional judgment. It is too narrow of an approach that focuses on small, discrete pieces of an integrated functional task or movement. The alternative of a more functional, comprehensive movement screen is vitally important for understanding human function and identifying impairments and dysfunctional movement patterns that diminish the quality of function. In many cases, weakness or tightness of a muscle or group is often identified and then treated with isolated stretching or strengthening activities instead of using a standard movement pattern that could address several impairments at once. Likewise, many professionals often focus on a specific region of complaint instead of beginning by identifying a comprehensive movement profile and relating the profile to dysfunction.
Fundamentals First
Where does one start with the examination and assessment of something as complex as human function? Standard, frequently used, fundamental or general movements would seem the logical place to start. To prepare an athlete for the wide variety of activities needed to participate in the demands of sport, analysis of fundamental movements should be incorporated into preparticipation screening. Assessment of fundamental movements can help the rehabilitation professional determine who possesses or lacks the ability to perform a wide variety of essential movements. The authors believe that assessment of fundamental or composite movements is necessary before the assessment of highly specific or specialized motions or movements. Consider the following statements in the context of assessment of an athlete:
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What appears to be muscular weakness may in fact be muscular inhibition.
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Identifiable weakness in a prime mover may be the result of a dysfunctional stabilizer or group of muscular stabilizers.
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Diminished function in an agonist may actually be dysfunction of the antagonist.
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What is described as muscular tightness may in fact be protective muscle tone leading to guarding and inadequate muscle coordination during movement.
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“Bad” technique might be the only option for an individual performing poorly selected, “off-target” exercises.
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Diminished general fitness may be related to the increased metabolic demand required by patients who use inferior neuromuscular coordination and compensations.
It is vital that fundamental, essential movements be examined to develop a working hypothesis regarding the source of the dysfunction. This approach allows the rehabilitation professional to see the big picture and attempt to discern the cause of the dysfunction rather than just identifying and treating specific, isolated impairments. This fundamental first approach, typically used when teaching a motor skill, holds true for assessment and correction of movement.
The Mobility-Stability Continuum
Movement becomes less than optimal (dysfunctional) as a result of breakdowns in parts of the movement system. Typically, such breakdowns are described as mobility or stability dysfunction. Unfortunately, the terms mobility and stability are not universally defined and can imply different things to clinicians with different backgrounds. For this reason it is important to describe the approach of the authors regarding descriptions of mobility and stability.
Mobility dysfunction can be broken down into two unique subcategories:
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Tissue extensibility dysfunction involves tissues that are extraarticular. Examples include active or passive muscle insufficiency, neural tension, fascial tension, muscle shortening, scarring, and fibrosis.
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Joint mobility dysfunction involves structures that are articular or intraarticular. Examples include osteoarthritis, fusion, subluxation, adhesive capsulitis, and intraarticular loose bodies.
Stability dysfunction may include an isolated muscular weakness or joint laxity, but it is frequently more complex and refers to multiple systems that are involved in the complex construct known as motor control. To account for the complexity of a stability problem, the term stability motor control dysfunction (SMCD) is used. SMCD is an encompassing, broad description of problems in movement pattern stability. Traditionally, stability dysfunction is often addressed by attempting to concentrically strengthen the muscle groups identified as stabilizers of a region or joint. This approach neglects the concept that true stabilization is reflex driven and relies on proprioception and timing rather than isolated, gross muscular strength. By using the term SMCD to distinguish stability problems, the clinician is forced to consider the central nervous system (CNS), peripheral nervous system, motor programs, movement organization, timing, coordination, proprioception, joint and postural alignment, structural instability, and muscular inhibition, as well as the absolute strength of the stabilizers. The concepts of mobility and stability are discussed further in the context of the Selective Functional Movement Assessment (SFMA) later in this chapter.
The purpose of this chapter as part of a sports medicine rehabilitation text is to provide the context for and convince the reader of the importance of a timely, accurate, and reproducible functional movement assessment. Though a part of examination, isolated measurements and quantitative assessments are not enough to capture the essence of functional movement in activities of life.
Movement screening, testing, and assessment
Athletic trainers screen during the preseason. Physical therapists are involved in screening, prevention, and wellness initiatives. Physicians serve patients by medically or surgically fixing problems but also attempt to prevent repeat injury. The number one risk for injury is previous injury. What contributes to this paradigm? Poor screening that does not identify athletes at risk for injury? Poor rehabilitation that does not finish the job? Poor or untested surgical or medical interventions that do not get to the root of the problem? Each is a possibility, and all disciplines may be responsible for unsuccessfully preparing or providing the building blocks for full return to movement normalcy. It is the job of all health professionals to adequately screen, test, assess, and identify movement dysfunction and offer solutions to restore movement efficiency and normalcy.
At this point it is important to distinguish between screening, testing, and assessment ( Table 22-1 ). This chapter is written to enhance the reader’s ability to comprehensively assess the movement (recall the previous discussion of movement versus motion) of patients, athletes, and clients. Many would argue that assessment of movement is important before embarking on a physical performance endeavor because the ability to move provides the foundation for the ability to perform physical fitness activities, work and athletic tasks, and basic activities of daily living. It is important to be able to distinguish dysfunctional movement from normal movement during preparticipation or preseason screening, as well as during postinjury or postoperative rehabilitation. It is also important to acknowledge that training through or despite poor movement patterns reinforces poor quality of movement and is likely to increase the risk for injury and predispose to greater levels of dysfunction. Even highly skilled athletes may have fundamental imperfections in movement.
| Term | Definition | Meaning |
|---|---|---|
| Screening | A system for selecting suitable people; to protect somebody from something unpleasant or dangerous | To create grouping and classification; to check risk |
| Testing | A series of questions, problems, or practical tasks to gauge knowledge, experience, or ability; measurement with no interpretation needed | To gauge ability |
| Assessment | To examine something; to judge or evaluate it; to calculate a value based on various factors | To estimate inability |
The authors of this chapter propose that the astute sports medicine professional combine the tasks of screening, testing, and assessment to systematically ascertain the risk, ability, or inability of each athlete, patient, or client. The outcome of such a logical and refined procedure would provide the caregiver the best possible information to formulate opinions regarding readiness for participation or return to sport.
Therefore, screening might come first in the assessment process, and the outcome of a useful, practical movement screening tool or approach would allow the provider to do the following:
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Demonstrate movement patterns that produce pain within expected ranges of movement
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Identify individuals with nonpainful but limited movement patterns who are likely to demonstrate higher potential risk for injury with exercise and activity
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Identify specific exercises and activities to avoid until competency in the required movement is achieved
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Identify and logically link screening movements to the most effective and efficient corrective exercise path to restore movement competency
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Build a description of standardized, fundamental movement patterns against which broader movement can be compared
Sahrmann, Kendall, and Janda have each offered valuable perspectives regarding human movement, posture, and function. They have been instrumental in describing examination of structural as well as functional symmetry or lack thereof. Rehabilitation professionals have progressed from examination of isolated muscles and posture to appreciation of the necessity of examining complex movement patterns.
There are numerous ways in which slight subtleties in movement patterns contribute to specific muscle weaknesses. The relationship between altered movement patterns and specific muscle weaknesses requires that remediation address the changes to the movement pattern; the performance of strengthening exercises alone will not likely affect the timing and manner of recruitment during functional performance. —Dr. Shirley Sahrmann
The transition from analysis of motion to analysis of functional movement and movement patterns helps rehabilitation providers discern the underlying cause of the dysfunction or imbalance. This paradigm shift propels rehabilitation providers toward the big picture, cause-and-effect, and regional interdependence thinking necessary for success in the twenty-first century.
Most would agree that it is difficult to qualitatively discern the quality of movement unless provided with a framework for making a judgment. Systematic screening, testing, and assessment of movement require not only a framework but also benchmarks or criteria that define the proper method of performing a movement. The authors of this chapter propose three possible general outcomes of movement assessment ( Table 22-2 ) as determined by comparison between the movement performed by the athlete and predetermined descriptors of success.
| Outcome | Description |
|---|---|
| Acceptable | Movement is good enough to allow the individual to be cleared for activity without an increase in risk for injury. |
| Unacceptable | Movements are dysfunctional and the individual may be at risk for injury unless movement patterns are improved. |
| Painful | Screening movements produce pain. Currently injured regions require additional, more advanced movement and physical assessment, including imaging, by a qualified health care provider. |
Training through or despite identified “poor” movement patterns reinforces poor quality and increases the risk for injury even during low-stress activities and the possibility of progression to greater movement dysfunction. Training and functional exercise techniques and strategies are covered in the next chapter ( Chapter 23 ); however, it is important to note here that that poor movement patterns must be identified and addressed before embarking on high-level functional training.
Movement related to injury potential and return from injury
The greatest risk for injury is a history of previous injury, and this fact has been demonstrated in a wide variety of populations and athletes. Yet how might this relate to an uninjured athlete or worker? Are there certain “markers” or performance measures that could separate high-quality, proper or correct movement from low-quality, improper or incorrect movements? Conceptually, if movement is dysfunctional, all activities, including activities of daily living, work tasks, and athletic performance built on that dysfunction, may be flawed and predispose the individual to increased risk for the development of even greater dysfunction. This statement is true even when dysfunctional base movements are masked by apparently acceptable, age-appropriate, and even highly skilled performance. It is possible to move poorly and not experience pain and, conversely, to move well and yet experience pain. Over time, poor movement patterns and dysfunctional movement strategies are likely to produce pain. An example might be a gymnast with an exaggerated lordosis that is functional for her sport but is likely, over time, to result in facet joint compression in the lumbar spine and decreased flexibility of the hip flexors. It is important to note that although poor movement patterns may increase risk for injury with activity, good movement patterns do not guarantee decreased risk for injury. It is the job of the astute health care professional to target and address identifiable risk factors, such as tight muscles, weak muscles, or poor balance or coordination during movement, and their biomechanical influences on movement. When poor movement patterns are addressed, proper movement must be enhanced with appropriate strength, endurance, coordination, and skill development, but proper movement comes first !
The functional movement screen and the selective functional movement assessment
The two movement assessment systems described in this chapter work together and use some common patterns of movement, but each possesses unique aspects. They serve to provide common language and “thinking” between a wide variety of health and fitness professions. Both are about the assessment of quality and not so much about the assessment of quantity of movement. Both stress the clinician’s ability to rate performance quality, rank and describe the greatest dysfunction, and measure, if necessary, within the context of foundational, general movements.
The Functional Movement Screen
The Functional Movement Screen (FMS) is a predictive, but not diagnostic functional screening system. The FMS is an evaluation or screening tool created for use by professionals who work with patients and clients for whom movement is a key part of exercise, recreation, fitness, and athletics. It may also be used for screening within the military, fire service, public safety, industrial laborers, and other highly active workers. This screening tool fills the void between preparticipation/preplacement screening and specific performance tests by examining individuals in a more general dynamic and functional capacity. Research has suggested that tests that assess multiple facets of function such as balance, strength, range of motion (ROM), and motor control simultaneously may assist professionals in identifying athletes at risk for injury.
The FMS, described by Cook et al, is composed of seven fundamental movement patterns that require a balance of mobility and stability for successful completion. These functional movement patterns were designed to provide observable performance tasks that relate to basic locomotive, manipulative, and stabilizing movements. The tests use a variety of common positions and movements appropriate for providing sufficient challenge to illuminate weakness, imbalance, or poor motor control. It has been observed that even individuals who perform at high functional levels during normal activities may be unable to perform these simple movements if appropriate mobility or stability is not present. An important aspect of this assessment system is its foundation on principles of proprioception and kinesthesia. Proprioceptors must function in each segment of the kinetic chain and associated neuromuscular control must be present for efficient movement patterns to occur.
The FMS is not intended for use in individuals displaying pain during basic movement patterns or in those with documented musculoskeletal injuries. Painful movement is covered subsequently in the section on the SFMA. The FMS is for healthy, active people and for healthy, inactive people who want to increase their physical activity. Interrater reliability of the FMS has been reported by Minick et al to be high, which means that the assessment protocol can be applied and reliable scores obtained by trained individuals when standard procedures are adhered to.
The FMS consists of seven movement patterns that serve as a comprehensive sample of functional movement ( Box 22-1 ). Additionally, three clearing tests, each associated with one of the FMS movement patterns, assess for pain with shoulder rotation motions, trunk extension, or trunk flexion.
- 1.
Deep squat
- 2.
Hurdle step
- 3.
In-line lunge
- 4.
Shoulder mobility test
- 5.
Active straight leg raise
- 6.
Trunk stability push-up
- 7.
Rotatory stability test
A kit for FMS testing is available commercially ( www.performbetter.com ); however, simple tools such as a dowel, 2 × 0.6 inches board, tape, tape measure, a piece of string or rope, and a measuring stick are enough to complete the testing procedures. When conducting the screening tests, athletes should not be bombarded with multiple instructions about how to perform the tests; rather, they should be positioned in the start position and offered simple commands to allow achievement of the test movement while observing their performance. The FMS is scored on an ordinal scale, with four possible scores ranging from 0 to 3 ( Table 22-3 ). The clearing tests mentioned earlier consider only pain, which would indicate a positive clearing test and requires a score of 0 for the test with which it is associated. Three is the highest or best score that can be achieved on any single test, and 21 is the best total score that can be achieved.
| A Score of… | Is Given If… |
|---|---|
| 0 | At any time during testing the athlete has pain anywhere in the body. Note: The clearing tests consider only pain, which would indicate a “positive” clearing test and requires a score of 0 for the test with which it is associated. |
| 1 | The person is unable to complete the movement pattern or is unable to assume the position to perform the movement. |
| 2 | The person is able to complete the movement but must compensate in some way to complete the task. |
| 3 | The person performs the movement correctly, without any compensation. |
The majority of the movements test both the right and left sides, and it is important that the sides be scored independently. The lower score of the two sides is recorded and used for the total FMS score, with note made of any imbalances or asymmetry occurring during performance of the task. ( Fig. 22-1 ) The creators of the FMS suggest that when in doubt, the athlete should be scored low.
Seven Movement Patterns of the Functional Movement Assessment
The deep squat ( Fig. 22-2, A to C )
The squat is a movement needed in most athletic events; it is the “ready position” that is required for many power movements such as jumping and landing. The deep squat assesses bilateral, symmetric mobility and stability of the hips, knees, ankles, and core. The overhead position of the arms (holding the dowel) also assesses the mobility and symmetry of the shoulders and thoracic spine. To perform a deep squat, the athlete starts with the feet at approximately shoulder width apart in the sagittal plane. The dowel is grasped with both hands, and the arms are pressed overhead while keeping the dowel in line with the trunk and the elbows extended. The athlete is instructed to descend slowly and fully into a squat position while keeping the heels on the ground and the hands above the head.
The hurdle step ( Fig. 22-3, A and B )
The hurdle step is designed to challenge the ability to stride, balance, and perform a single-limb stance during coordinated movement of the lower extremity (LE). The athlete assumes the start position by placing the feet together and aligning the toes just in contact with the base of the hurdle or 2 × 6-inch board. The height of the hurdle or string should be equal to the height of the tibial tubercle of the athlete. The dowel is placed across the shoulders below the neck, and the athlete is asked to step up and over the hurdle, touch the heel to the floor (without accepting weight) while maintaining the stance leg in an extended position, and return to the start position. The leg that is stepping over the hurdle is scored.
In-line lunge ( Fig. 22-4, A and B )
The in-line lunge attempts to challenge the athlete with a movement that simulates dynamic deceleration with balance and lateral challenge. Lunge length is determined by the tester by measuring the distance to the tibial tubercle. A piece of tape or a tape measure is placed on the floor at the determined lunge distance. The arms are used to grasp the dowel behind the back with the top arm externally rotated, the bottom arm internally rotated, and the fists in contact with the neck and low back region. The hand opposite the front or lunging foot should be on top. The dowel must begin in contact with the thoracic spine, back of the head, and sacrum. The athlete is instructed to lunge out and place the heel of the front/lunge foot on the tape mark. The athlete is then instructed to slowly lower the back knee enough to touch the floor while keeping the trunk erect and return to the start position. The front leg identifies the side being scored.
Shoulder mobility ( Fig. 22-5, A to C )
This mobility screen assesses bilateral shoulder ROM by combining rotation and abduction/adduction motions. It also requires normal scapular and thoracic mobility. Begin by determining the length of the hand of the athlete by measuring from the distal wrist crease to the tip of the third digit. This distance is used during scoring of the test. The athlete is instructed to make a fist with each hand with the thumb placed inside the fist. The athlete is then asked to place both hands behind the back in a smooth motion (without walking or creeping them upward)—the upper arm in an externally rotated, abducted position (with a flexed elbow) and the bottom arm in an internally rotated, extended, adducted position (also with a flexed elbow). The tester measures the distance between the two fists. The flexed (uppermost) arm identifies the side being scored.
Shoulder Clearing Test ( Fig. 22-6 )
After the previous test is performed, the athlete places a hand on the opposite shoulder and attempts to point the elbow upward and touch the forehead (Yocum test). If painful, this clearing test is considered positive and the previous test must be scored as 0.
Active straight leg raise ( Fig. 22-7 )
This test assesses the ability to move the LE separately from the trunk, as well as tests for flexibility of the hamstring and gastrocnemius. The athlete begins in a supine position, arms at the side. The tester identifies the midpoint between the anterior superior iliac spine (ASIS) and the middle of the patella and places a dowel on the ground, held perpendicular to the ground. The athlete is instructed to slowly lift the test leg with a dorsiflexed ankle and a straight knee as far as possible while keeping the opposite leg extended and in contact with the ground. Make note to see where the LE ends at its maximal excursion. If the heel clears the dowel, a score of 3 is given; if the lower part of the leg (between the foot and the knee) lines up with the dowel, a score of 2 is given; and if the patient is only able to have the thigh (between the knee and the hip) line up with the dowel, a score of 1 is given.
Trunk stability push-up ( Fig. 22-8, A and B )
This test assesses the ability to stabilize the spine in anterior/posterior and sagittal planes during a closed chain upper body movement. The athlete assumes a prone position with the feet together, toes in contact with the floor, and hands placed shoulder width apart (level determined by gender per criteria described later) ( Table 22-4 ), as though ready to perform a push-up from the ground. The athlete is instructed to perform a single push-up in this position with the body lifted as a unit. If unable, the hands should be moved to a less challenging position per criteria and a push-up attempted again. The chest and stomach should come off the floor at the same instance, and no lag should occur in the lumbar spine.
| Position Level | Male | Female |
|---|---|---|
| III | Thumbs aligned with the forehead | Thumbs aligned with the chin |
| II | Thumbs aligned with the chin | Thumbs aligned with the clavicle |
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