What have movement screens done for you lately? Why the movement screen was never meant to predict injury.

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The humble screen, my how you have grown! So big and useful you have grown! What great things you can do now movement screen! Not just a little movement screen anymore are you? 

Thank you for tuning into another instalment of my blog. I had planned to write this blog before the more recent BJSM post and other interesting media outlets, so this is quite topical at present and seemingly serendipitous.

The rise of the movement screen

Informally, the process of movement screening has probably been around for as long as humans have walked the earth; humans have always assessed and evaluated the way another human moves. On screening movement you can check if the other caveman is threatening, welcoming, wounded or lame, stronger or weaker than you and you can make a quick decision from there. Formally, this process is newer. It comes in many forms; check out these links for some examples:
– http://movementscreen.com.au/movement-screening-system/movement-screening/
– Australian Rugby Union has a few, here is a brief description of one.

The most prolific of all movement screens has been the Functional Movement Screen, created by four very smart blokes with an incredible amount of work; I don’t think anyone will ever doubt that. Very troubling is the fact that most of their literature comes endorsed by the very system they are trying to investigate. Here is a very quick summary of the literature on the FMS:

 Reliability: Established early in the piece but  Teyhen et al in 2012 provided some backing for this. This was only within 2 raters and 10 participants mind you. Two recent systematic reviews and meta-analyses, one in 2016  and one in 2017 show that the FMS does at least have good inter and intra-rater reliability. It seems common sense, that a systematic approach to look at something should demonstrate that it is pretty hard to mess up and go too far off track.
– Performance association: A big trial by Chapman, Laymon & Arnold demonstrated that track and field athletes with a lower score on the FMS did not improve in performance like their counterparts who scored higher. Athletes that had 1 or more asymmetry performed worse than those who were symmetrical and athletes that scored 1 on the deep squat movement performed worse than those who scored 2 or 3. It would seem intuitive that athletes who have a left-right difference won’t perform as well in a sport that is largely single-legged. It would also seem intuitive that those athletes that can’t perform a squat very well, the very exercise that is prolific in many strength and conditioning programs, won’t be very efficient in enhancing their performance; because the coach can’t get them to squat!
– Injury risk prediction: Proposed in a seminal paper by Kyle Kiesel in 2007.  Now one of the main-stays of their literature arsenal and the most hotly-debated topic.  Some of the main headlines –

  •  The developers of the FMS do actively promote the association between injury risk and their screen on their website – see all articles here 
  • The use of a composite score shown to be ineffective at predicting injury by a large systematic review.
  • BJSM incorrectly calls a – yes very FMS like – movement screen that is actually not the trademarked FMS and claims the FMS system incapable of predicting injury. See post here. What the story actually looks like is The “9+ screening test”, was shown to be ineffective at predicting injury in a robust prospective trial. Really this is very damning piece of research and it does seem like the larger cohort trials are coming up with the same conclusion time and time again.

​So, the FMS has fairly rapidly moved from being the darling of the health and fitness world, capable of so much, to being downtrodden by the mainstream sports medicine literature.

So what is the crux of the question? Injuries are about more than movement.

The movement screen was never designed to predict injury. Something as complicated as injury cannot be predicted on movement alone.

Movement is one small (BUT INCREDIBLY COMPLEX) part of the process. Let’s put it this way, you don’t even have to move to get injured; think postural pain in athletes. Screening is one small part of the process towards finding out more about an athlete or a patient and their ability to move. A part of your data gathering process, if you want to make it systematic, then you need to use a systematic approach. It is finding out whether they can actually just perform the ‘basic’ movement patterns that most modern day practitioners use in order to strengthen or rehabilitate someone. After you find out if they can or can’t do the movement pattern you require – or screen them – the authors of FMS have proposed you then assess their performance in these – or similar – movement patterns. If there are any issues along the way you stop and assess the actual reason why they can’t do it.

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There is no diagnostic process in a screen, nor was there every meant to be. There is no prediction of injury from a screen and in my opinion Kyle Kiesel made a huge error in reasoning when he proposed injury risk association. So why don’t we all accept this, move on and stop arguing a moot point.  It will be (or now has been?) advantageous for the field of health and fitness to stop thinking of the FMS as a magic bullet, but throwing stones doesn’t really get anyone anywhere.

Screening is just one part of the process. Generally a screen leads to a dichotomised outcome; in a movement screen’s case it is,  ‘can the athlete perform the movement you are after or not?’ If not, it is down to the clinician to determine why not. Again, a screen does not diagnose anything. Let alone, crystal ball into future athletic endeavours and predict injury. Injury is about (amongst a myriad of others):
– Appropriate loading; see Gabbett’s 2016 landmark paper,
– External variables out of the control of the athlete and/or coach,
– Stress and mental wellness,
And yes, then the massive topic of movement; neuromuscular control, stability, muscle mechanical ‘hardware’, efficiency of contraction. It just isn’t all about whether they can perform a squat or lunge. What is needed is to plug movement screening values into a multi-logistic regression model with other variables like loading and stress and then determine the exact weighting of movement screening amongst other injury variables in predictive strength. 

Does it even assess movement?

This is, in my opinion, probably the argument we ought to be having instead of whether movement screens can predict injury. Movement is formed from billions of inputs and one glorious output. It is the ultimate in complex behaviour, at least in my opinion. I work with what it arguably the most popular movement screen – the FMS – every day, so I think I can speak on its utility to a certain degree of qualification.

Besides what the above paragraphs may look like I actually think the FMS is an incredibly useful tool for the following reasons:

  • The Overhead Deep Squat is one of the best ‘mobility’ screens you can ask for. Can the athlete get into extreme dorsiflexion, knee and hip flexion with combined thoracic extension and glenohumeral flexion? All loaded under gravity? If not, then asses and adapt for your required exercise and outcome. Or correct this pattern if your goal is a deep squat.
  • The trunk stability push up is a great assessment of posterior chain activation. Plain and simple.

I think it’s a big omission to not have any pulling movements in the FMS, but for 20+ years of thought and effort, I do honestly think it is a great overall screen of basic human movement patterns.
The only real negative I personally have with the FMS is its structure. Funnily enough this is probably its biggest strength. Human movement is insanely complex, beautiful, wide-ranging and it is hard to think that you can gather all the information you need to with a screen of 7 basic tasks. I have a background of Ido Portal’s movement approach and read a fair bit into Frans Bosch, so my view on this is that movement is too complex to even attempt to box it in. What may be a ‘flaw’ for one person, may be a strength to another. Some of the best athletes out there have what are traditionally considered movement flaws.

Systemising your approach to assessing an athlete’s movement is STILL important though, and if your strength and conditioning or rehabilitation program includes the elements of the FMS, then use it! It is simpler and fairly comprehensive for most programs out there. But why the hell does the squat archetype have to be with the toes pointed forward? Different squats for different hips folks..

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But I may leave the question of ‘whether the movement screen actually screens movement’ up to you. What do you think?
https://www.youtube.com/watch?v=ts4sEBb2K3s

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