It’s strange how things work out sometimes. I recently did a talk on the issues and limitations with screening for injury prevention at the Arsenal Sports Medicine Conference. I then have an online disagreement with some promoters of a ‘new’ functional movement screening mat making some bold claims about its predictive ability. Then I get Stuart Wright an Athletic Trainer and Strength and Conditioning Coach from the UK now living and working in the US at Limestone College, South Carolina send me this brilliant blog on why he thinks we should abandon ALL functional movement assessments. It’s almost like the universe has a grand plan for us to keep challenging outlandish claims and bullshit around movement flaws… Anyway it’s over to Stuart to explain why we should abandon ALL movement assessments… enjoy!
Why we should abandon functional movement assessments! At least for now!
Currently movement assessments include, but are not limited to rolling techniques, the Functional Movement Screen (FMS), the Selective Functional Movement Assessment (SFMA), and Janda’s movement assessment. One thing all of these assessments have in common is that there is weak or low level evidence regarding injury prediction. While this is not the purpose of each assessment it is a common area of concern regarding movement screening and assessment.
Currently, two systematic reviews evaluating the predictive ability of the FMS are in disagreement.1,2 The SFMA is written as commentary, or expert opinion (Level 5).3 The book by Page, exploring the Janda assessment is lacking in evidence based justification for the volume of information presented.4 The article reviewing rolling techniques by Hoogenboom is also level 5 evidence.5 However, despite the astounding lack of evidence (Or low level/poor strength of recommendation)6,7 in this field, clinicians routinely utilize one of these (or a variation of these) in their clinical practice.
One of the main concerns surrounding this area is the lack of validity. Validity states that an instrument assesses what it intends to assess.8 With movement assessment we do not know why are we using these movement assessments. Cook stated in his keynote address in 2013 that the FMS is for non-medical professionals (So why are medical professionals so keen to use it?), but he also stated it will foster prediction, prognosis and exercise prescription.9 Currently none of this has been proven. While there are differences between the movement assessments regarding purpose and execution some global questions still exist:
- Will the utilization of the assessments lead to a reduction in injuries?
- Will movement assessment result in better rehabilitation?
- Will movement assessment improve the daily function of non-athletic and athletic populations?
None of this has been proven with sufficient evidence. At present there is a paucity of research that can answer any of these questions, therefore we must take a step back and ask ourselves again; why are we doing this? It is critical that patient reported outcome measures should be validated, and rightfully so; however this is not true for movement assessments; These assessments are largely based on theory alone.
What is dysfunctional?
In addition, terminology is something has had received little attention. The term dysfunctional or even functional movement is questionable. Different authors and clinicians look to assess and correct dysfunctional movement, but we still lack a good definition and consensus with this term. The term dysfunctional movement carries a negative connotation and is therefore viewed as such. It is important to really question this term as it is imperative within movement assessment.
The dynamic systems theory (DST) can illustrate the issue with the definition of dysfunctional movement. By altering the degrees of freedom, there are multiple combinations of movements, and if one component is lacking another component can alter their contributions to enable completion of the task.10 From this perspective it makes it very difficult to argue that any movement is in fact dysfunctional.
The sensorimotor system has the ability to organize itself based on the complexity of the task, the environment the task is performed in, as well as the organisms capacity to execute the task.10 This can be interpreted that the body is actually a wonderful unique system that has the ability to adapt, and one movement that is not right for one patient in a given situation may be appropriate to another patient in a completely different environment.
The term redundancy is also utilized within DST, stating that the sensorimotor system numerous options for completing specific movement tasks.10 Therefore, from a sensorimotor perspective the terms functional and dysfunctional depend entirely on the person, their environment and task. It would be prudent to suggest a completely different term be used when looking at what is simply just variability of movement, and may not be ‘dysfunctional’. If our operationalized definition for the outcome used is inappropriate all research surrounding dysfunctional movement becomes invalid. Perhaps a more patient oriented approach not be considered.
Self reported dysfunction?
One study found a connection between low back pain and the FMS. The study used a patient self-report measure, which indicates there is potential to integrate movement assessment with self-report of function.11 Allowing patients to define function as it relates to themselves, using validated methods/questionnaires fits much better in the patient oriented, evidence based culture in sports medicine. Evidence based practice and patient oriented evidence are considered the highest evidence, and of the utmost importance in our field, so defining dysfunctional movement for our patients is not appropriate. Allowing our patients to provide information that is important to them (as it is done in all other areas of sports medicine/physical therapy), should be prioritized.
While Cook states the FMS is not supposed to be diagnostic,12 he did claim it could predict injury and provide prognosis.9 The SFMA is not designed to predict 3 but is designed to evaluate movement related pain.3 While many of the assessments in the SFMA are logical, none are validated with evidence; which allows clinicians and readers to be suspicious of such an assessment. Again Cook states the SFMA is not diagnostic, but provides a mapping of movement patterns. Each of the movement assessments mentioned were developed and were supposed to be utilized in different ways.
The FMS can be used as a screen by non-medical practitioners to potentially identify those that require further investigation, which seems like a plausible and reasonable suggestion, but this again is expert opinion and nothing more. There is no proof that forwarding on those with apparent dysfunction to medical staff benefit from such a system, especially from a patient oriented perspective. In addition, Rhinehart et al,. state if a movement assessment is used as post-therapeutic assessment it is used to assess effectiveness of the therapeutic intervention.13
The authors have made this claim, but offer no objective criteria, and provide no operationalized definitions. It is not possible to make this claim when there is no definition of a successful outcome. Overall, the screen and movement assessments are not backed up by high levels of evidence, they are not diagnostic, and there is a lack of objective information was an outcome assessment, so we have to question why they are continuously utilized.
Evidence more than opinion!
On the other hand we currently have high levels of evidence that neuromuscular programs reduce the incidence of injuries; the FIFA 11+ is one such tool.14 So let’s stop trying to predict injury with assessments that are not intended to do such a thing and simply implement tools that have good evidence. Many modifiable risk factors have been identified in different patient populations for different injuries, and I am certain they will continue to increase in number. Therefore, these movement assessments as they have been practiced in a global sense should be abandoned.
There is a need to go back to the drawing board and figure out how these tools can benefit the patients. More importantly, there is a need to figure out how we can demonstrate benefit to our patients with good evidence before simply using a tool because it appears to make sense.
If you ask me, would I use these screens in clinical practice? As it stands, in the way that the screens have be produced and utilized, not at all. The profession has made strides to encourage practitioners to use evidence based therapeutic interventions, but this same standard is not upheld with regards to movement assessment. I do appreciate the underlying theory behind movement. Changes in movement from altered afferent input into the sensorimotor system, may cause changes in efferent output. Changes associated with the tensegrity of the human body, pain, and posture within a cycle of resulting in a movement one does not consider optimal.
The first thing to do with movement assessment is truly define why it is being used. If this first step is not completed appropriately, clinicians are wasting their time, and more importantly, wasting the patients time. Cook also states that the FMS is supposed to review movement in a 1x body weight situation and extrapolations beyond this should not be.3 However, based on the influence of the sensorimotor system one could also argue movement assessment should be conducted after a stressful match/training session to review movement in a fatigued state. If the sensorimotor system is affected by input into the system, review of a non fatigued individual provides little insight into movement during the environments that actually matter to the patient. But again, no evidence to date is available to support or refute this claim.
Movement assessment also ignores tissue capacity. One person may move differently from another, but their ability to withstand the loading on their structures may be just fine. Gabbett et al recently proved the usefulness of the acute/chronic workload ratio for injury.15 While the team have repeatedly stated their number of 1.5 is not a magic number, they have demonstrated that monitoring a patient/athletes load is better at predicting injury that assessment of movement.15 A true movement assessment should look at both quality and quantity. Mechanotransduction is an extremely important consideration in injury and rehabilitation. The ability for tissue to respond to biomechanical loads placed upon them is imperative to tissue function and capacity.16,17, It also relates to the tensegrity based theory of structure. The body is potentially made up of interconnected segments under intermittent compression and continuous tension.18 Changes in these structures can theoretically alter pain, and movement, but this is not possible without mechanotransduction. Therefore, ignoring strength, tissue structure and capacity, whilst simply looking at movement quality ignores a vital aspect screening.
Bahr states there is currently no intervention study providing support for screening for injury risk,19 In addition, Wright states that methodological limitations, accuracy statistics, limit the use of FMS as a screening tool,20 supporting the skepticism of using movement assessments. The end goal should be to reduce morbidity, or to increase function. However, without patient input it is not possible to provide a comprehensive definition of functional and dysfunctional movements. In support of this Saw et al,21 demonstrated subjective measures were more sensitive than objective measures with regards to injury prediction.21
Overall, upon review of the evidence available for movement assessment and compare it to evidence in other areas of sports medicine, it is obvious that there is problem. Ultimately, there are still significantly more questions that require an answer before movement assessments should be utilized consistently throughout the field. Therefore, clinicians should set their bias aside (myself included) and come together to see where these assessments could be beneficial. Therefore, as it stands movement assessment should be abandoned, for now; but it should also investigated further as there is a space in the field for movement assessment, we just have to find out where, using good and clear evidence.
Finally, there are additional reasons to screen your patients, and it is up to the clinician to understand the benefit and limitations, however screening should be a comprehensive medical overview not a quick assessment of movement.
References available here