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[ research report ]
More than 10 000 Amer-icans seek medical treat-ment for sports,
re-creational activity, and
exercise-related injuries on a daily basis.20 Researchers have
estimated that 50% to 80% of these injuries are overuse innature
and involve the lower extrem-ity.1,11,25 In the military, physical
training and exercise-related injuries account for 30% of
hospitalizations and 40% to 60% of all outpatient visits, with 10
to 12 inju-ries per 100 soldier-months.12 Although the risk of
musculoskeletal conditions and injuries is
multifactorial,7,9,10,15,17-19 preliminary evidence suggests that
neuro-muscular and strength training programs may be beneficial for
preventing the oc-currence of these conditions.7,9,10,15,17-19
However, tools that assess movement to help predict those at
highest risk for musculoskeletal conditions and injuries have been
lacking for both athletic and military populations. The Functional
Movement Screen (FMS) is a relatively new tool that attempts to
address mul-tiple movement factors, with the goal of predicting
general risk of musculoskeletal
TT STUDY DESIGN: Reliability study.TT OBJECTIVES: To determine
intrarater test-
retest and interrater reliability of the Functional Movement
Screen (FMS) among novice raters.
TT BACKGROUND: The FMS is used by various examiners to assess
movement and predict time-loss injuries in diverse populations (eg,
youth to professional athletes, firefighters, military service
members) of active participants. Unfortunately, critical analysis
of the reliability of the FMS is currently limited to 1 sample of
active college-age participants.
TT METHODS: Sixty-four active-duty service members (mean SD age,
25.2 3.8 years; body mass index, 25.1 3.1 kg/m2) without a history
of injury were enrolled. Participants completed the 7 component
tests of the FMS in a counterbalanced order. Each component test
was scored on an ordinal scale (0 to 3 points), resulting in a
composite score ranging from 0 to 21 points. Intrarater test-retest
reliability was assessed between baseline scores and those obtained
with repeated testing performed 48 to 72 hours later. Interrater
reliability was based on the assessment from 2 raters, selected
from a pool of 8 novice raters, who assessed the same movements on
day 2 simultaneously. Descriptive statistics, weighted kappa (w),
and percent agreement were calcu-lated on component scores.
Intraclass correlation coefficients (ICCs), standard error of the
measure-ment, minimal detectable change (MDC95), and associated 95%
confidence intervals (CIs) were calculated on composite scores.
TT RESULTS: The average SD score on the FMS was 15.7 0.2 points,
with 15.6% (n = 10) of the participants scoring less than or equal
to 14 points, the recommended cutoff for predicting time-loss
injuries. The intrarater test-retest and interrater reliability of
the FMS composite score resulted in an ICC3,1 of 0.76 (95% CI:
0.63, 0.85) and an ICC2,1 of 0.74 (95% CI: 0.60, 0.83),
respectively. The stan-dard error of the measurement of the
composite test was within 1 point, and the MDC95 values were 2.1
and 2.5 points on the 21-point scale for interra-ter and intrarater
reliability, respectively. The inter-rater agreement of the
component scores ranged from moderate to excellent (w =
0.45-0.82).
TT CONCLUSION: Among novice raters, the FMS composite score
demonstrated moderate to good interrater and intrarater
reliability, with accept-able levels of measurement error. The
measures of reliability and measurement error were similar for both
intrarater reliability that repeated the assessment of the movement
patterns over a 48-to-72hour period and interrater reliability that
had 2 raters assess the same movement pattern si-multaneously. The
interrater agreement of the FMS component scores was good to
excellent for the push-up, quadruped, shoulder mobility, straight
leg raise, squat, hurdle, and lunge. Only 15.6% (n = 10) of the
participants were identified to be at risk for injury based on
previously published cutoff values. J Orthop Sports Phys Ther
2012;42(6):530-540, Epub 14 May 2012.
doi:10.2519/jospt.2012.3838
TT KEY WORDS: injury prediction, injury preven-tion, injury
risk, interrater, intrarater
1Commander, US Army Public Health Command Region-South, Fort Sam
Houston, TX. 2Associate Professor, US Army-Baylor University, Fort
Sam Houston, TX. 3Physical Therapy Intern, US Army-Baylor
University, Fort Sam Houston, TX. 4Assistant Professor, US
Army-Baylor University, Fort Sam Houston, TX. 5Researcher, TRUE
Research Foundation, San Antonio, TX. 6Director of Musculoskeletal
Research, Department of Physical Therapy (MSGS/SGCUY), 81st Medical
Group, Keesler Air Force Base, Biloxi, MS. This research study was
approved by the Brooke Army Medical Center Institutional Review
Board. The views expressed herein are those of the authors and do
not reflect the official policy or position of Brooke Army Medical
Center, the US Army Medical Department, the US Army Office of the
Surgeon General, the Department of the Army, Department of the Air
Force, Department of Defense, or the US Government. Address
correspondence to Dr Deydre S. Teyhen, US Army-Baylor University,
3151 Scott Road, Room 1303 (ATTN: MCCS-HGE-PT), Fort Sam Houston,
TX 78234. E-mail: [email protected] or
[email protected]
DEYDRE S. TEYHEN, PT, PhD1,2 SCOTT W. SHAFFER, PT, PhD2 CHELSEA
L. LORENSON, PT3 JOSHUA P. HALFPAP, PT3
DUSTIN F. DONOFRY, PT3 MICHAEL J. WALKER, PT, DSc4 JESSICA L.
DUGAN, PT5 JOHN D. CHILDS, PT, PhD2,6
The Functional Movement Screen: A Reliability Study
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conditions and injuries.3-5,13,14,16
The FMS was designed to identify functional movement deficits
and asym-metries that may be predictive of general musculoskeletal
conditions and injuries, with an ultimate goal of being able to
modify the identified movement deficits through individualized
exercise prescrip-tion.3,4 The FMS consists of 7 fundamen-tal
movement component tests (FIGURE 1) that are scored on a scale of 0
to 3, with the sum creating a composite score rang-ing from 0 to 21
points.3,4 The 7 move-ment patterns that are assessed include the
deep squat, in-line lunge, hurdle step, shoulder mobility, active
straight leg raise, trunk stability push-up, and quad-ruped rotary
stability.
Preliminary research by Kiesel et al14 suggests that National
Football League (NFL) players (n = 46) who had a com-posite score
less than or equal to 14 on the FMS had an odds ratio of 11.7 (95%
confidence interval [CI]: 2.5, 54.5) and a positive likelihood
ratio of 5.8 (95% CI: 2.0, 18.4) to sustain a time-loss injury.
Al-though the specificity was relatively high (0.9; 95% CI: 0.8,
1.0), the sensitivity was low (0.5; 95% CI: 0.3, 0.7), indicating
that FMS composite scores less than or equal to 14 may suggest
higher injury risk but FMS composite scores greater than 14 do not
rule out future injury risk. In a separate study on a group of
Marines, a composite score less than or equal to 14 on the FMS
demonstrated limited abil-ity to predict all future musculoskeletal
injuries (traumatic or overuse), with a sensitivity of 0.45 and
specificity of 0.71, while the same cutoff value was able to
predict a serious injury (any injury that was severe enough to
remove the par-ticipant from the training program) with a
sensitivity of 0.12 and a specificity of 0.94.21 The FMS was also
able to predict injury risk in female collegiate athletes.2
Finally, in another study, firefighters with a previous history of
injury demonstrated lower FMS composite scores.23 However, it is
not clear for which sports or profes-sions the FMS is optimal in
predicting injury risk, what types of musculoskel-
etal injuries are predicted by low FMS composite scores, and
whether the origi-nal cutoff score of less than or equal to 14
points on the FMS is valid in the different populations.
Additionally, researchers have found that FMS composite scores
increased in football players,13 firefighters,6 and service
members8 following corrective exercises that addressed possible
impair-ments associated with altered movement patterns noted on the
FMS component tests. In a group of Marines, 80% of those with a
score less than or equal to 14 also demonstrated lower fitness
scores on a standardized fitness test compared to those who had an
FMS composite score greater than 14.21 However, Okada et al22 found
that FMS composite scores were not related to performance or core
stabil-ity measures among healthy participants.
Interpretation of FMS scores is lim-ited by the scant evidence16
regarding the FMS's psychometric properties and, in particular, the
reliability of both com-posite and individual component scores. An
initial study by Minick et al16 found acceptable levels of
interrater agreement on the FMS component scores among
novice and expert raters in a sample of active college-age
participants (to in-clude college varsity athletes). However, this
study had several limitations: (1) it did not assess test-retest
reliability, (2) all raters assessed the same movement pattern via
videotaped analysis, and (3) it only assessed agreement of
individual FMS component scores and did not as-sess the overall FMS
composite score, which is typically used as the primary indicator
of injury risk. Traditionally, the FMS is assessed in real time,
with-out the benefit of video playback. Vari-ability of human
movement across trials theoretically should exist; therefore,
test-retest analysis could lower the reported agreement values.
Additionally, the FMS is often assessed in a group setting (eg,
preseason physical or preparticipation screening), requiring the
use of multiple raters, who may or may not be the same raters to
assess the movement at follow-up testing. Therefore, a more robust
reli-ability study is required to enhance the understanding of the
psychometric prop-erties of the FMS.
Although these initial FMS studies, which established the
validity of the FMS
FIGURE 1. Functional Movement Screen tests. (A) In-line lunge,
(B) hurdle step, (C) deep squat, (D) quadruped rotary stability,
(E) active straight leg raise, (F) shoulder mobility, and (G) trunk
stability push-up.
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[ research report ]for predicting musculoskeletal conditions and
injuries and the response to training, are encouraging, their data
are prelimi-nary and not published in widely accessi-ble journals.
Exploring the psychometric properties of the FMS in a large active
population would enhance the general-izability of the previous
findings beyond a limited subgroup of professional and collegiate
athletes and students. The primary purpose of this study was to
de-termine the intrarater (test-retest) and interrater reliability
of the FMS com-ponent and composite scores in young, healthy
service members, when tested by a counterbalance group of novice
raters in real time. Specifically, agreement was assessed on the
FMS component scores, whereas reliability, response stability, and
error threshold measurements were ob-tained for the FMS composite
scores. A secondary purpose of this study was to describe the FMS
component and com-posite scores in this population.
METHODS
Participants
Theconveniencesampleincludedparticipants who were recruited over
an 8-week period from service
members in training at Fort Sam Hous-ton, TX. Potential
participants were provided a briefing about the study and were
given the opportunity to volunteer. Participants were eligible for
inclusion if they were between the ages of 18 and 35 years or
emancipated minors (17-year-olds who are considered adults and
al-lowed to join the armed services), fluent in English, and had no
current or previ-ous complaint of lower extremity pain, spine pain,
or medical or neuromuscu-loskeletal disorders that limited
partici-pation in work or exercise in the last 6 months.
Participants were excluded if they were currently seeking medical
care for lower extremity injuries or had pre-vious medical history
that included any surgery for lower extremity injuries.
Par-ticipants were also excluded if they were unable to participate
in physical training
due to other musculoskeletal injuries; had a history of fracture
(stress or trau-matic) in the femur, pelvis, tibia, fibula, talus,
or calcaneus; or were known to be pregnant.
Potential participants were provided an overview of the research
study and specific details of the entrance criteria. After the
presentation was completed, those who met the entrance criteria
were asked to squat and then hop unilaterally on each leg in the
group setting. Individ-uals who met the entrance criteria and did
not have pain on the squat and hop tests were informed about
upcoming data collection dates. Those individuals who opted to
volunteer returned the follow-ing week to sign informed consent
forms and were enrolled in the study. Within the military training
environment, these procedures allowed potential partici-pants the
option to not return if they were not interested in volunteering in
the study, and were designed to minimize any
potential perception of coercion. All par-ticipants signed
consent forms approved by the Brooke Army Medical Center
In-stitutional Review Board.
ExaminersThe novice examiners participating in this study
consisted of 8 physical therapy students enrolled in their second
and third semesters of a doctor of physical therapy training
program prior to their 1-year clinical internship. Before testing,
all examiners underwent 20 hours of FMS training led by 4 physical
therapists and 1 research assistant. Four physical therapy students
were randomly as-signed to the participants to assess intra-rater
test-retest reliability by assessing the FMS on day 1 and day 2.
The goal of randomly selecting a rater to perform the intrarater
test-retest reliability was to increase the variability in the
study design. Each rater used for the intrarater test-retest
reliability measured between
TABLE 1 Demographics
Abbreviation: CI, confidence interval.
Type Mean SD 95% CI
Age, y 25.2 3.8 24.3, 26.2
Height, cm 175.5 9.6 173.1, 177.9
Weight, kg 77.5 12.5 74.4, 80.7
Body mass index, kg/m2 25.1 3.1 24.3, 25.9
TABLE 2 FMSDescriptiveAnalysis*
Abbreviation: FMS, Functional Movement Screen.*The data
displayed represent the first analysis of rater 1 on the first day
of data collection (n = 64).
FMS Component Score
Test 0 1 2 3 Mean SD
Trunk stability push-up 0 7 29 27 2.3 0.7
Quadruped rotary stability 0 3 56 5 2.0 0.3
Shoulder mobility 0 2 19 43 2.6 0.6
Active straight leg raise 0 1 36 27 2.4 0.5
Deep squat 0 3 42 19 2.3 0.5
Hurdle step 0 1 51 12 2.2 0.4
In-line lunge 0 1 29 33 2.5 0.5
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14 and 18 participants. There were no differences in outcomes
across raters, so aggregate data were analyzed.
A second set of 4 physical therapy stu-dents were randomly
assigned to view the participants movement simultaneously with the
first set of raters for the inter-rater reliability assessment on
day 2. To minimize bias, raters were randomly as-signed, raters for
day 2 were blinded to day 1 raters measurements, pairs of rat-ers
on day 2 were blinded to each other's analysis and scoring, and 48
to 72 hours of time elapsed between intrarater test-retest
reliability measurements. The goal of having a random set of 2
raters assess each participant was to increase the vari-ability in
the study design to more closely mimic field conditions, which
often in-clude mass screenings that utilize mul-tiple raters.
ProceduresThe FMS is composed of 7 component tests used to
assess different fundamental movement patterns.3-5 Participants
com-pleted the component tests in a coun-terbalanced order,
including the deep squat, hurdle step, in-line lunge, shoulder
mobility, active straight leg raise, trunk stability push-up, and
quadruped rotary stability tests (FIGURE 1). Five of 7 compo-nent
tests assess asymmetry by measuring the test bilaterally. If
discrepancies exist between the left and right sides, asymme-try is
noted for that component test and the lower of the 2 scores is
included in the FMS composite score. In addition to the 7 component
tests, the FMS includes 3 clearing tests that assess for pain:
shoul-der internal rotation and abduction with the hand placed on
the opposite shoulder, lumbar extension performed in the prone
press-up position, and end-range lumbar flexion in quadruped. Pain
on a clearing test resulted in a score of 0 for the shoul-der
mobility, trunk stability push-up, or rotary stability test,
respectively. Partici-pants performed all tests without a
pre-participation warm-up.
Each component test was scored on an ordinal scale (0 to 3
points), based
on the quality of movement, with 3 be-ing the maximum score.3-5
A score of 2 indicated that the participant required some type of
compensation or was un-able to complete the entire movement. A
score of 1 was given if the individual was unable to remain in the
movement posi-tion throughout the movement, lost bal-ance during
the test, or did not meet the minimum criteria to score a 2. Pain
dur-ing any of the FMS component tests or during any of the
clearing tests indicated a score of 0. All participants were
allowed to perform each component test up to 3 times, and the
maximal score achieved was recorded. The scores of the compo-nent
tests were summed, resulting in a composite score from 0 to 21
points, with 21 being the maximum composite score. Additional
details on scoring of each of the component tests and the composite
score are provided elsewhere3-5 and in the APPENDIX.
Statistical AnalysisDescriptive statistics and frequency counts
were calculated. Agreement of the component tests was analyzed with
a weighted kappa statistic. The weighted kappa scores were as
follows: 80% and higher, excellent agreement; from 60% to 79.9%,
substantial levels of agreement; from 40% to 59.9%, moderate
agree-ment; and below 40%, poor to fair agree-ment.24 Reliability
of the composite test scores was analyzed using intraclass
cor-relation coefficients (ICCs). ICC values of 0.75 and above
represent good reliability, those between 0.50 and 0.74 represent
moderate reliability, and those below 0.50 indicate poor
reliability.24 Intrarater test-retest reliability was assessed
using an ICC3,1 model, while interrater reliabil-ity was assessed
using an ICC2,1 model. Response stability of the intrarater and
interrater reliability of the composite scores was calculated using
the standard error of the measurement (SEM) at the 95% level of
confidence. The minimal detectable change (MDC95) values at the 95%
level of confidence were calculated to determine error thresholds.
Statistical
analyses were conducted using SPSS Ver-sion 17.0 (SPSS Inc,
Chicago, IL).
RESULTS
Sixty-four participants (53 males, 11 females) met the inclusion
and exclusion criteria and complet-
ed the study (TABLE 1). The mean SD age of the participants was
25.2 3.8 years and their body mass index was 25.1 3.1 kg/m2.
Overall, the participants in-cluded routine exercisers who endorsed
a statement that they exercised a mini-mum of 4 days per week (n =
54, 78.2%). Although the participants were attending training for
their military occupation, the majority of the participants were
routine exercisers for more than 3 years. Specifi-cally, 29 (45.3%)
participants reported performing routine exercise for more than 5
years, 21 (32.8%) for 3 to 5 years, 9 (14.1%) for 1 to 3 years, and
5 (7.8%) for less than 1 year. Descriptive statistics on FMS
performance are provided in TABLE 2. None of the participants had
pain on the 3 FMS clearing tests. Interrater reliability was
calculated on 63 participants, based on an illness of 1 of the
raters on day 2 of testing. Only 15.6% (n = 10) of the
par-ticipants were identified to be at risk for injury, based on an
FMS composite score of less than or equal to 14 points.
Agreement of the 7 component tests of the FMS (scored 0 to 3)
demonstrated moderate to excellent interrater agree-ment (TABLE 3).
Specifically, the novice raters demonstrated excellent interrater
agreement on the trunk stability push-up; substantial interrater
agreement on the quadruped rotary stability, deep squat, active
straight leg raise, hurdle step, and shoulder mobility component
tests; and moderate interrater agreement on the in-line lunge.
Intrarater (test-re-test) agreement scores at 48 to 72 hours
demonstrated substantial agreement on the trunk stability push-up,
shoulder mo-bility, active straight leg raise, deep squat, and
in-line lunge component tests; mod-erate agreement on the hurdle
step; and poor agreement on the quadruped rotary
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[ research report ]
stability component test.The interrater reliability (same
day)
of the FMS composite score (scored 0-21) resulted in an ICC2,1
of 0.76 (95% CI: 0.63, 0.85) and was considered good (TABLE 4). The
SEM for interrater reliabil-ity of the composite test was 0.92
points, and the MDC95 was 2.54 points on the 21-point scale. Visual
representation of the FMS composite scores between rat-ers is
provided in FIGURE 2. The intrarater reliability (test-retest at 48
to 72 hours) of the FMS composite scores resulted in an ICC3,1 of
0.74 (95% CI: 0.60, 0.83) and was considered to be moderate (TABLE
4). Visual representation of the intrarater test-retest FMS
composite scores is pro-vided in FIGURE 3. The SEM for
intrarater
test-retest reliability was 0.98 points and the MDC95 was 2.07
points.
DISCUSSION
TheFMShasanadequatelevelofreliability when assessed in healthy
service members by novice raters.
The interrater agreement of the FMS component scores ranged from
moder-ate to excellent, with 6 of the 7 tests cat-egorized as
having substantial agreement (w60%). The intrarater and interrater
point estimates of the FMS composite score reliability ranged from
0.74 to 0.76, with the 95% CIs suggestive of moderate to good
reliability. The SEMs for both interrater and intrarater
reliability were
less than 1 point, while the MDC95 ranged from 2.1 to 2.5 points
on the 21-point scale. The SEM and MDC values were similar for both
intrarater reliability that repeated the assessment of the movement
patterns over a 48-to-72hour period and interrater reliability that
had 2 raters as-sess the same movement pattern simul-taneously.
Therefore, one can expect the error of measurement to be within 1
point across raters and across time, while a minimum improvement
between 2 and 3 points on the 21-point scale would be required to
demonstrate a real change over time.
These results are consistent with a prior publication on FMS
reliability. Minick et al16 reported substantial to ex-cellent
interrater agreement on individ-ual FMS component scores when using
2 novice and 2 expert raters assessing videotape performance of
active college-age students and varsity athletes. Add-ing to the
literature, our study provides detailed information on the
intrarater and interrater reliability of both FMS component and
composite scores by randomly assigned novice raters. Spe-cifically,
our study utilized 8 entry-level physical therapy students as
raters to collect data prior to their clinical intern-ship.
Additionally, these raters measured all movements in real time,
without the benefit of being able to replay a video-tape (the
methodology used by Minick et al16). The increased number of raters
and real-time analysis of movement in mul-tiple participants in our
study mimic a preparticipation screening environment, thus enhance
the generalizability of the results. Further research is needed to
as-sess the stability of the FMS scores over longer periods.
Ultimately, the reliability of this group of novice raters was
com-parable to previously published research and provides further
support for the FMS as a reliable tool to screen in a relatively
diverse, noncollegiate but physically ac-tive population.16
Only 15.6% (n = 10) of the partici-pants in this study had an
FMS compos-ite score less than or equal to 14 points.
TABLE 3AgreementofFMSComponent
Scores(0-3points)
Abbreviations: CI, confidence interval; FMS, Functional Movement
Screen.
Type/Test Percent Agreement w 95% CI
Interrater
Trunk stability push-up 78 0.82 0.73, 0.90
Quadruped rotary stability 92 0.77 0.57, 0.96
Shoulder mobility 86 0.73 0.57, 0.89
Active straight leg raise 84 0.69 0.51, 0.87
Deep squat 83 0.68 0.51, 0.85
Hurdle step 88 0.67 0.45, 0.88
In-line lunge 68 0.45 0.25, 0.65
Intrarater
Trunk stability push-up 68 0.68 0.55, 0.81
Quadruped rotary stability 83 0.29 0.05, 0.50
Shoulder mobility 81 0.68 0.53, 0.80
Active straight leg raise 80 0.60 0.42, 0.74
Deep squat 88 0.76 0.63, 0.85
Hurdle step 86 0.59 0.42, 0.73
In-line lunge 83 0.69 0.48, 0.77
TABLE 4ReliabilityofFMSComposite
Scores(0-21points)
Abbreviations: CI, confidence interval; FMS, Functional Movement
Screen; ICC, intraclass correlation coefficient; MDC95, minimal
detectable change at the 95% level of confidence; SEM, standard
error of measurement.
Type ICC 95% CI SEM MDC95Interrater 0.76 0.63, 0.85 0.92
2.54
Intrarater (test-retest) 0.74 0.60, 0.83 0.98 2.07
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Although this may not seem surprising, given that the
participants were relative-ly healthy, it supports the suggestion
by Cook et al3,4 that FMS scores can identify altered movement
patterns in generally healthy and pain-free participants. Our
results are similar to those published by OConnor et al,21 who
found that 10% of the 874 Marine officer candidates scored less
than or equal to 14 points on the FMS. If the initial research that
identified the cutoff value were validated, it would suggest that
the FMS would be capable of identifying a subset of individuals at
increased risk for time-loss injury within a population of young,
healthy service members. Based on the use of the FMS for mass
screenings (eg, preseason or an-nual physical examinations), an
injury prediction screening that could identify only 15.6% of the
population as having a high injury risk would allow the asso-ciated
medical staff to prioritize the al-location of limited resources
toward the development of individualized injury prevention
interventions (eg, corrective exercise prescriptions) for this
group. However, the validity of the 14-point cut-off score for this
sample cannot be verified in this study, because longitudinal
follow-up was not performed to assess actual in-jury rates. Based
on the SEM of 1 point and the MDC95 value between 2.1 and 2.5
points, it would be more conservative to use a cutoff score of 15
(based on SEM) or 16 to 17 (based on MDC95) to determine those who
may benefit from corrective exercise prescription to help mitigate
in-jury risk, until the validity of the 14-point cutoff value can
be determined.
One of the limitations noted in the FMS component tests was a
restriction in the range of scores. Specifically, based on our
inclusion/exclusion criteria, no participants scored a 0 on any of
the FMS component tests, and only 18 of the 446 scored movement
patterns resulted in a score of 1; the remaining movement patterns
either received a score of 2 or 3. This restriction in range might
have reduced the reliability estimates of the FMS component scores.
For example,
the in-line lunge was determined to have a weighted kappa of
0.45; for this test, no movements were scored as a 0 or 1.
Ad-ditionally, only 11 of the 63 paired ratings had a disagreement,
with 25 agreements for a score of 2 and 27 agreements for a
score of 3. Compared to the other FMS component scores, the
in-line lunge and the quadruped rotary stability had the biggest
discrepancy between the percent agreement (68% and 83%,
respectively) and weighted kappa (0.45 and 0.29, re-
Rate
r 2
Rater 1
12 13 14 15 16 17 18 19 Total
12 2 1 1 0 0 0 0 0 4
13 1 0 1 0 0 0 0 0 2
14 1 2 1 0 0 0 0 0 4
15 0 0 3 4 3 0 0 0 10
16 0 1 4 1 6 1 0 0 13
17 0 0 1 3 3 2 3 2 14
18 0 0 0 1 1 6 4 0 12
19 0 0 0 0 0 1 1 1 3
20 0 0 0 0 0 0 0 1 1
Total 4 4 11 9 13 10 8 4 63
FIGURE 2. Comparison of Functional Movement Screen composite
scores between rater 1 and rater 2. Green boxes indicate agreement
(n = 20), yellow boxes indicate a composite-score difference of
only 1 point (n = 27), and orange boxes indicate a composite-score
difference of 2 to 3 points (n = 16).
FMS
Day
1 Co
mpo
site
Sco
re
FMS Day 2 Composite Score
12 13 14 15 16 17 18 19 Total
10 1 0 0 0 0 0 0 0 1
11 0 0 0 0 0 0 0 0 0
12 1 1 1 0 0 0 0 0 3
13 2 1 1 1 0 0 0 0 5
14 0 1 1 1 2 1 0 0 6
15 0 1 2 5 3 1 0 0 12
16 0 0 5 0 4 3 1 0 13
17 0 0 0 2 4 1 2 0 9
18 0 0 1 0 1 2 4 4 12
19 0 0 0 0 0 2 0 0 2
20 0 0 0 0 0 0 1 0 1
Total 4 4 11 9 14 10 8 4 64
FIGURE 3. Comparison of FMS composite scores for rater 1 (day 1
to day 2). Green boxes indicate agreement (n = 17), yellow boxes
indicate a composite-score difference of only 1 point (n = 26),
orange boxes indicate a composite-score difference of 2 to 3 points
(n = 20), and the red box indicates a composite-score difference
greater than 3 points (n = 1). Abbreviation: FMS, Functional
Movement Screen.
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12. Jones BH, Knapik JJ. Physical training and exercise-related
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13. Kiesel K, Plisky P, Butler R. Functional move-
spectively). Interestingly, the lowest levels of agreement
between novice raters for both our study and Minick et al16
involved the in-line lunge and quadruped rotary stability tests.
Difficulty in performing the quadruped rotary stability test (only
5 of the 64 participants obtained a score of 3 on day 1) also
limited variability and potentially intrarater agreement of this
measure. Although the restricted range might have influenced
statistical calcula-tions, it is important to point out that rat-er
experience and lack of clearly defined scoring criteria, especially
mid-range performance, may have also influenced results for these
select measures. Future research should determine whether bet-ter
criteria may help to differentiate levels of performance on the
quadruped rotary stability test or to determine the influ-ence of
removing the quadruped rotary stability test on the predictive
validity of the FMS composite score.
Future study designs should assess the reliability of the FMS
using novice raters and participants with varying activity levels
and sport-specific requirements. Additional longitudinal studies
are also required to establish the predictive va-lidity and optimal
cut score for various populations. This level of critical
investi-gation would help to enhance the external validity of the
FMS and to substantiate its use in the general clinical population,
as well as in specific sports settings. Future research should also
determine whether there is a ceiling effect in the ability of the
FMS to detect change over time. Based on the MDC95 of 2.1 to 2.5
points, posi-tive change may not be able to be noted for
individuals who score greater than 18 points at baseline testing.
Different scoring criteria or cutoff values may be needed to better
differentiate high-end performance on the FMS.
CONCLUSIONS
Among novice raters, the FMScomposite score demonstrated
moderate to good interrater and
intrarater reliability, and acceptable lev-
els of measurement error. The measures of reliability and
measurement error were similar for both intrarater reliability that
repeated the assessment of the move-ment patterns over a
48-to-72hour pe-riod and interrater reliability that had 2 raters
assess the same movement pattern simultaneously. The interrater
agreement of the FMS component scores was good to excellent for the
push-up, quadru-ped, shoulder mobility, straight leg raise, squat,
hurdle, and lunge. Only 15.6% (n = 10) of the participants were
identified as being at risk for injury based on previ-ously
published cutoff values. t
KEYPOINTSFINDINGS: When using novice raters, the FMS composite
scores had moderate to good reliability (ICC = 0.74 and 0.76; SEM,
1.0 points; MDC95, 2.1 and 2.5 points) and the FMS component scores
ranged from moderate to excellent agreement (w =
0.29-0.82).IMPLICATIONS: The FMS has adequate re-liability when
assessed in young, healthy service members by novice raters over a
48-to-72hour period.CAUTION: Reliability data must be inter-preted
within the context of the sample tested and the methods used (ie,
time between testing for test-retest reliability estimates).
ACKNOWLEDGEMENTS: This study was done in collaboration with
research assistants from the University of Texas Health Science
Center, Physical Therapy Department, San Antonio, TX: Mark
Bauernfeind, Francis Bisagni, Jor-dan Boldt, Cindy Boyer, Cara
Dobbertin, Steve Elliot, Angela Gass, Germaine Herman, Lacey Jung,
Jake Mitchess, Teddy Ortiz, Kelly Rabon, Jason Smith, Megan Swint,
Joshua Trock, and Jerry Yeung. Additional research assistants from
US Army-Baylor University, Depart-ment of Physical Therapy, US Army
Medical Department Center and School, San Anto-nio, TX: First
Lieutenant Moshe Greenberg, Captain Sarah Hill, First Lieutenant
Crys-tal Straseske, First Lieutenant Sarah Villena, First
Lieutenant Christina Yost, First Lieu-tenant Kristen Zosel, First
Lieutenant Rick
Warren, and First Lieutenant Sam Wood. Illustrations for the
APPENDIX were provided by Elizabeth Holder.
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| number 6 | june 2012 | 537
MORE INFORMATIONWWW.JOSPT.ORG@
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intervention program in professional football players. Scand J Med
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http://dx.doi.org/10.1177/0363546504272261
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18. Myer GD, Ford KR, McLean SG, Hewett TE. The effects of
plyometric versus dynamic stabiliza-tion and balance training on
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FUNCTIONAL MOVEMENT SCREENScore Criteria Illustration
Deep Squat
3 Upper torso is parallel with tibia or toward vertical Femur
below horizontal Knees are aligned over feet Dowel aligned over
feet
2 Performed with heels on 2 6-in board Upper torso is parallel
with tibia or toward vertical Femur below horizontal Knees are
aligned over feet Dowel aligned over feet
1 Performed with heels on 2 6-in board If any of the 4 criteria
are not met when the squat is performed with
heels on 2 6-in board, the score is 1
0 Pain during test
APPENDIX
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Score Criteria Illustration
Hurdle Step (test both right and left sides)*
3 Foot clears cord (does not touch) and remains dorsiflexed as
leg is lifted over hurdle
Hips, knees, and ankles remain aligned in the sagittal plane
Minimal to no movement is noted in lumbar spine Dowel and hurdle
remain parallel
2 Alignment is lost between hips, knees, and ankles Movement is
noted in lumbar spine Dowel and hurdle do not remain parallel
1 Contact between foot and hurdle Loss of balance is noted
0 Pain during test
In-line Lunge (test both right and left sides)*
3 Knee touches board behind heel Dowel and feet remain in
sagittal plane Dowel contacts remain (head, thoracic spine, sacrum)
Dowel remains vertical, no torso movement noted
2 Knee does not touch behind heel Dowel and feet do not remain
in sagittal plane Dowel contacts do not remain Dowel remains
vertical Movement is noted in torso
1 Loss of balance is noted Inability to achieve start position
Inability to touch knee to board
0 Pain during test
Active Straight Leg Raise (test both right and left sides)*
3 Malleolus of tested lower extremity located in the region
between mid-thigh and anterior superior iliac spine of opposite
lower extrem-ity (green region)
Opposite hip remains neutral (hip does not externally rotate),
toes remain pointing up
Opposite knee remains in contact with board
2 Malleolus of tested lower extremity located in the region
between mid-thigh and knee joint line of opposite lower extremity
(yellow region) while other criteria are met
1 Malleolus of tested lower extremity located in the region
below knee joint line of opposite lower extremity (red region)
while other criteria are met
0 Pain during test
APPENDIX
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Score Criteria Illustration
Shoulder Mobility (test both right and left sides)*
3 Fists are within 1 hand length
2 Fists are within 1.5 hand lengths
1 Fists are not within 1.5 hand lengths
0 Pain during testShoulder mobility clearing test: if pain is
noted as elbow is lifted,
shoulder mobility is scored as 0
Trunk Stability Push-up
3 Perform 1 repetition; the thumbs are aligned with forehead for
males and chin for females
Body is lifted as 1 unit (no sag in lumbar spine)
2 Perform 1 repetition; the thumbs are aligned with chin for
males and clavicle for females
Body is lifted as 1 unit (no sag in lumbar spine)
1 Unable to perform 1 repetition with thumbs aligned with chin
for males and clavicle for females
0 Pain during testExtension clearing test: if pain is noted
during a prone press-up, push-
up is scored as 0
APPENDIX
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Score Criteria Illustration
Quadruped Rotary Stability (test both right and left sides)*
3 1 unilateral repetition (lift arm and leg from same side of
body) Keep spine parallel to board Knee and elbow touch in line
over the board and then return to the
start position
2 1 diagonal repetition (lift arm and leg from opposite sides of
body) Keep spine parallel to board Knee and elbow touch in line
over the board and then return to the
start position
1 Inability to perform diagonal repetition
0 Pain during testFlexion clearing test: if pain is noted during
quadruped flexion, rotary
stability is scored as 0
*For component tests that are scored for both the right and left
sides, the lower score is used when calculating the Functional
Movement Screen composite score.
APPENDIX
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