Monday, October 10, 2016

The False Reality of the FMS

The Functional Movement Screen (FMS) is a popular screen used by coaches and sports medicine professionals as a screen for movement competency.  It is composed of 7 movements and scored on a 0-3 scale, where 0 = pain, 1 = couldn't perform the task, 2 = performed task with compensation, 3 = performed task correctly.

The scores from the 7 movements are combined into a final score out of 21.  The score is supposed to predict injury and performance and it is even suggested that scores under 14 predict a greater risk of injury.

The FMS claims to identify compensatory movement patterns that are indicative of increased injury risk and inefficient movement that causes reduced performance.

That's a pretty big claim and one the FMS has NOT lived up to.  

First and foremost, the FMS is supposed to be a SCREEN and unfortunately practitioners far out-reach the boundaries of a screen when applying the FMS.  The FMS places labels on people and their movement and with anything that places labels, we certainly hope there is some strong evidence that supports these labels.

This is tremendously important because when someone scores poorly on a test, they get told their chance of getting injured is high and their performance is decreased. This only implants fear and guarding in the client, rather than confidence and overall is a great way to build fear of movement and sport.  Coaches and those in sports medicine NEED to get beyond telling clients that because they score poorly on a test, they'll get injured - this isn't beneficial to anyone.

Again, the FMS is supposed to be used as a screen, NOT a diagnostic tool… it doesn't and should NOT be used to diagnose things.  Yet, I hear people all over, use the FMS to diagnose supposed dysfunction.

It is a baseline screen, and honestly only scratches the surface of what else needs to be assessed. I have heard of athletes who performed the FMS on them, and then get told rash diagnoses and/or put fear in the athlete basically saying that it's a miracle they can even make it through a day of school with all the dysfunction's they have.

"You shouldn't squat based on your OH Squat assessment; 
your core is sooo weak; you have tight hamstrings - you shouldn't sprint; 
you have an asymmetrical rotary stability score - you will get injured if you don't improve it"

Given all radical leaps in faith the FMS asserts, let's take a closer look at various aspects of the FMS and their claims


The FMS claims to identify compensatory movement patterns that are indicative of increased injury risk and inefficient movement that causes reduced performance.


This is the big one I'll address because it claims an awful lot, and as you'll see, without much scientific support.

In order for the FMS, or any screen for that matter, to be a valid indicator of injury or inefficient movement in sport, it is logical that the compensatory movement patterns that are tested during the screen must be the same or similar to those that are performed in sport - which the FMS does not (Beardsley)
  • Dossa et al. (2014) studied junior level hockey players to see if the FMS could predict injuries throughout a season.  The researchers concluded the FMS could NOT be recommended as a screening tool for injury prevention.
  • McCall et al. (2015) reviewed the scientific level of evidence of three of the most commonly-reported risk factors, screens, and injury prevention exercises in a previously published survey of 44 premier league soccer teams. The FMS was one of the identified screens. They assigned the FMS a grade D, where D = insufficient evidence to assign a specific recommendation.  
  • Parchmann et al. (2011) studied the FMS to evaluate whether it was related to sport performance and found there were NO significant correlations between the higher FMS scores and on-field sports performance.
  • Even the founders of the FMS did a literature review on the FMS and stated “the use of a total FMS score for predicting injury risk should be avoided, as the individual components of the test are not correlated with one another and are therefore not measuring the same underlying variable" (Cook et al. (2014)).
  • Several researchers have assessed FMS scores on athletes of different ability levels to see if higher performing athletes scored higher on the FMS compared to lower level athletes.  They found there to be no difference between FMS scores and the level of the athlete.  This shows that the FMS does not and cannot predict performance. (Fox et al. 2013; Grygorowicz et al. 2013; & Loudon et al. 2014). 
  • Lockie et al. (2015) found very little correlation between FMS scores and multidirectional speed and jumping tests in healthy male subjects. 
  • In addition, many investigations have been performed to assess the correlations between sprinting, jumping, throwing and agility performances and FMS scores and most have found no relationship between any measure of athletic performance and FMS score (Okada et al. 2011; Parchman et al. 2011; Lockie et al. 2015b).
  • When it comes to predicting injury, Dallinga et al. (2012) reviewed the literature in respect of the tests that could predict a greater risk of injury.  They reported that general joint laxity, the Star Excursion Balance test, age, a lower hamstring-to-quadriceps strength ratio, and a reduced hip abduction range of motion could all predict a higher risk of lower body injuries.                        To test an aspect of this injury prediction model, Paszkewicz et al. (2013) investigated the association between total FMS score and Beighton and Horan joint mobility index (BHJMI) in adolescent athletes. They found no correlation between total FMS score and BHJMI index.  We also know the FMS can't target any of the other aspects shown by Dallinga et al. (2012) as being predictive of injury. 
  • A major flaw with the FMS is it's ability or lack of ability to distinguish between athletes. Shouldn't we assess individual variances between athletes in different sports?  A baseball player should definitely be assessed differently than a cross country runner or an offensive lineman in football.  Each one of these athletes will exhibit markedly different mechanical adaptations based on the demands of their sport and position.  Whose to say these adaptations are wrong or bad?  "Faulty" movement patterns do not always lead to pain or injury and in many cases these adaptations are what make athletes better performers in their sport.  Guess what, tissues positively adapt and get stronger based on the stresses placed on them… this is why a pitcher's arm will be very different from others - and this IS NOT a bad thing.  Poor posture does not mean its pathological nor does it mean that person will suffer from more musculoskeletal problems.  So can we please STOP TELLING ATHLETES THIS

The FMS Can Predict Injury


Short answer - NO IT DOESN'T
  • Schneiders et al. (2011) looked to find normative values in the FMS with young athletes.  They evaluated the FMS based on the assumption that identifiable biomechanical deficits in fundamental movement patterns have the potential to limit performance and render the athlete susceptible to injury.  In this study, the researchers found that healthy individuals and previously injured individuals had the same scores.  So the FMS could not even detect differences in injured individuals compared to healthy ones.  This is of concern as past injury is a main risk factor of future injury. If FMS cannot detect any sign of recent injuries, it seems unlikely that it can detect future risk, let alone be used as a basis for a specific therapy.
  • Frost et al. (2013) questioned the ability of the FMS to assess dysfunction. They looked at 21 firefighters who initially performed a standard screen followed by a repeat screen 5 minutes later, but on the 2nd trial participants were given a verbal description of the grading criteria before performing each test. All firefighters improved their scores within minutes of being told what movement patterns were required - The average score improved from 14.1 ± 1.8 to 16.7 ± 1.9 points; remember in just 5-MINUTES.  Therefore, changes in FMS score may not be due to actual improvements in mechanical efficiency such as mobility, stability or coordination of an athlete but rather simply a knowledge of what the task requires.   This isn't the first time this outcome has been shown, as there are indications that subjects may deliberately alter their movement patterns during the FMS test in order to score higher (Teyhen (2012); Schultz (2013)).  This is supposed to be a reliable screen?
  • To piggyback the last bullet point - The FMS sum score appears to be very reliable between raters (inter-rater) and within raters for a video of the same test (intra-rater). However as we just discussed, test-retest is less reliable, indicating that the same subjects may score differently on different occasions, despite there being no biomechanical changes made (Beardsley).
  • Okada et al. (2011) studied the relationship between FMS scores and "core" strength on actual sport performance.  To keep beating a dead horse, it was found "core" strength and FMS scores are NOT strong predictors of sports performance… yet PT's continues to tell clients/athletes core strength and quality FMS scores are important for performance and pain.
  • As I said earlier, it has been suggested that scores under 14 predict a greater risk of injury.  BUT, O'Connor et al. (2011) demonstrated that scores of 18 or more were more at risk for injury than those who scored less than 18 in 874 marine officers.  Scores above 14 are supposed to have decreased risk of injury, not the opposite, especially with a score so close to being perfect. 


These 7 Tests Predict Global Movement?

At the end of the day, it is a far stretch to think these 7 tests somehow can predict an athletes global movement, especially when the athlete is under load, speed, chaos, and fatigue.

Yet, some believe that these slow, safe, pre-planned, mostly static tests will predict dynamic movement.   It's one thing to do tests in a very controlled, passive type of environment compared to dynamic. I've seen a lot of good things in table assessments or FMS type screens, only to go to HELL under speed or load… Let this be clear, while these screens can have some benefit, they tend to have absolutely NO transfer to dynamic, reactive, and chaotic environments such as sport.

For example, what do we gain from the Overhead Squat (OHS)?

Let's be real here, using the OHS as an assessment of general movement ability, is like using a tennis serve to test coordination (Quote from Dr. Cobb of Z-Health).  The OHS is arguably the most complex version of a squat.  So instead of starting with a baseline test and a more basic squat version, we skip A-Y and go straight to Z. In addition, squatting while reaching overhead is not something that humans are designed to do. It is a skill, and anybody, the first time you ask them to perform something that is completely new to them will struggle.  Chances are, the faults you find in the OHS are due to a lack of performing this specific task as opposed to a lack of good general movement patterns.

Also, why are no other squat assessments used, such as adding a counter-weight (clarify mobility vs stability needs), taking a wide stance, letting toes track outward, using an asymmetrical stance, etc.

Nope, instead the FMS forces everybody to take a shoulder width stance with toes forward and discounts the fact that everybody's hip anatomy is different and to say that you need to be able to OHS with a shoulder-width stance, with toes forward is absurd… how are still on this? Take a look at the pictures below and tell me if these people should be judged on the same squatting scale given their vastly different anatomical structures.

It's like trying to fit a square peg into a round whole when we say you should be able to squat in this stance - to this depth and apply it to the whole population.






In Closing

This isn't to say that the FMS is useless, but let's be real, anybody with a grasp of anatomy and biomechanics can clearly see the gaps in reasoning in using solely the FMS as an assessment tool.

Now, the FMS and those who use it, do a wonderful job of marketing and "scaring" athletes/clients into thinking that because they scored poorly, they need additional training.  I mean, it's a beautiful system in a business sense, although as I've shown, it lacks support from research to do what it claims to do.

So a word of caution to athletes/clients/parents - usually those promoting the FMS have something to sell.  They'll show you where you're "lacking" and probably have some program that will "fix" these problems.

A word to coaches and professionals - come up with your own assessment that is based in science and evaluates the athlete not only statically, but dynamically and in a manner that is the same or similar to those that are performed in sport.  Also, please use tremendous caution when telling athletes/clients they are "broken" or dysfunctional or on their way to injury.  This is bad business and psychologically damaging to the athlete/client and only creates fear of movement.


Check out our Elite Performance Podcast for a little breakdown of what goes into our assessment process (Starting at 4:00-14:00min)




Go Get 'Em!


References:

       Beardsley - https://www.strengthandconditioningresearch.com/functional-movement-screen-fms/#CONT

       Cook, G., Burton, L., Hoogenboom, B. J., & Voight, M. (2014). Functional movement screening: the use of fundamental movements as an assessment of function-part 2. International journal of sports physical therapy, 9(4), 549-563
     
       Dallinga, J. M., Benjaminse, A., & Lemmink, K. A. (2012). Which Screening Tools Can Predict Injury to the Lower Extremities in Team Sports?. Sports medicine, 42(9), 791-815

       Dossa, K., Cashman, G., Howitt, S., West, B., & Murray, N. (2014). Can injury in major junior hockey players be predicted by a pre-season functional movement screen–a prospective cohort study. The Journal of the Canadian Chiropractic Association, 58(4), 421.

       Fox, D., O’Malley, E., & Blake, C. (2014). Normative Data for the Functional Movement Screen™ in Male Gaelic Field Sports. Physical Therapy in Sport.

       Frost, D. M., Beach, T. A., Callaghan, J. P., & McGill, S. M. (2013b). FMS™ scores change with performers’ knowledge of the grading criteria-Are general whole-body movement screens capturing” dysfunction”? The Journal of Strength & Conditioning Research.
       
       Grygorowicz, M., Piontek, T., & Dudzinski, W. (2013). Evaluation of Functional Limitations in Female Soccer Players and Their Relationship with Sports Level–A Cross Sectional Study. PloS one, 8(6), e66871
   
       Lederman E. The Myth of Core Stability. Journal of Bodyworks Movement Therapy. 2010 Jan;14(1):84–98.       

       Lockie, R. G., Schultz, A. B., Jordan, C. A., Callaghan, S. J., Jeffriess, M. D., & Luczo, T. M. (2015). Can selected functional movement screen assessments be used to identify movement deficiencies that could affect multidirectional speed and jump performance?. The Journal of Strength & Conditioning Research, 29(1), 195-205

       Loudon, J. K., Parkerson-Mitchell, A. J., Hildebrand, L. D., & Teague, C. (2014). Functional movement screen scores in a group of running athletes. The Journal of Strength & Conditioning Research, 28(4), 909-913

       McCall, A., Carling, C., Davison, M., Nedelec, M., Le Gall, F., Berthoin, S., & Dupont, G. (2015). Injury risk factors, screening tests and preventative strategies: a systematic review of the evidence that underpins the perceptions and practices of 44 football (soccer) teams from various premier leagues. British journal of sports medicine.

       Okada, T., Huxel, K. C., & Nesser, T. W. (2011). Relationship between core stability, functional movement, and performance. The Journal of Strength & Conditioning Research, 25(1), 252-261
    
       O’Connor, F. G., Deuster, P. A., Davis, J., Pappas, C. G., & Knapik, J. J. (2011). Functional movement screening: predicting injuries in officer candidates. Med Sci Sports Exerc, 43(12), 2224-30.

       Parchmann, C. J., & McBride, J. M. (2011). Relationship between functional movement screen and athletic performance. The Journal of Strength & Conditioning Research, 25(12), 3378-3384.
  
       Paszkewicz, J. R., & Cailee Welch McCarty, D. (2013). Comparison of Functional and Static Evaluation Tools Among Adolescent Athletes. The Journal of Strength & Conditioning Research.

       Schneiders, A. G., Davidsson, Å., Hörman, E. & Sullivan, S. J. (2011). Functional movement screenTM normative values in a young, active population. International Journal of Sports Physical Therapy, 6(2),75.


        Shultz, R., Anderson, S. C., Matheson, G. O., Marcello, B., & Besier, T. (2013). Test-Retest and Interrater Reliability of the Functional Movement Screen. Journal of athletic training, 48(3), 331-336

       Teyhen, D. S., Shaffer, S. W., Lorenson, C. L., Halfpap, J. P., Donofry, D. F., Walker, M. J., & Childs, J. D. (2012). The Functional Movement Screen: a reliability study. The Journal of Orthopaedic and Sports Physical Therapy, 42(6), 530-40

       Unsgaard-Tøndel M, Fladmark AM, Salvesen O, Vasseljen O. Motor Control Exercises, Sling Exercises, and General Exercises for Patients With Chronic Low Back Pain: A Randomized Controlled Trial With 1-Year Follow-up. Phys Ther. 2010 Jul.

2 comments:

  1. Thank you for sharing the interesting information. As I hoped, these info will be useful to many people.
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  2. excellent and useful article. But you forgot the benefit of the FMS: it allows us as trainers to pretend to ourselves we're physiotherapists, without the trouble of a five year degree and clinical practice.

    ReplyDelete