In both competitive athletes and the general population,

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1 PERFORMANCE COMPARISON OF STUDENT-ATHLETES AND GENERAL COLLEGE STUDENTS ON THE FUNCTIONAL MOVEMENT SCREEN AND THE YBALANCE TEST KATHERINE D. ENGQUIST, 1 CRAIG A. SMITH, 1,2 NICOLE J. CHIMERA, 3 AND MEGHAN WARREN 1 1 Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff, Arizona; 2 Proactive Physical Therapy, Tucson, Arizona; and 3 Department of Athletic Training, Daemen College, Amherst, New York ABSTRACT Engquist, KD, Smith, CA, Chimera, NJ, and Warren, M. Performance comparison of student-athletes and general college students on the Functional Movement Screen and the Y Balance Test. J Strength Cond Res 29(8): , 2015 Although various studies have assessed performance of athletes on the Functional Movement Screen (FMS) and the Y Balance Test (YBT), no study to date has directly evaluated a comparison of performance between athletes and members of the general population. Thus, to better understand the application of the FMS and the YBT to general college students, this study examined whether or not general college students performed similarly to student-athletes on the FMS (composite and movement pattern scores) and the YBT (composite and reach directions). This study evaluated 167 Division I studentathletes and 103 general college students from the same university on the FMS and the YBT. No difference was found in FMS composite scores between student-athletes and general college students. For FMS movement patterns, female studentathletes scored higher than general college students in the deep squat. No difference was found for men in any FMS movement pattern. Female student-athletes scored higher than female general college students in YBT composite scores; no difference was found for men in YBT composite scores. In analysis of YBT reach directions, female student-athletes scored higher than female general college students in all reach directions, whereas no difference was found in men. Existing research on the FMS composite score in athletic populations may apply to a general college population for the purposes of preparticipation screening, injury prediction, etc. Existing research on the YBT in male athletic populations is expected Address correspondence to Meghan Warren, meghan.warren@nau.edu. 29(8)/ Ó 2015 National Strength and Conditioning Association to apply equally to general college males for the purposes of preparticipation screening, injury prediction, etc. KEY WORDS FMS, YBT, Star Excursion Balance Test, screening, general population INTRODUCTION In both competitive athletes and the general population, musculoskeletal injury is an inherent risk with increasing physical activity/exercise (24,35). According to the Centers for Disease Control and Prevention (CDC), more than 10,000 people are seen in the country s emergency departments (EDs) each day for sports, recreation, and exercise (SRE) related musculoskeletal injuries (2). At least 1 in every 5 injury-related visits to the ED was the result of participation in SRE activities (2). Better understanding of the etiologic factors that predispose an individual to injury may mitigate the risk of SRE musculoskeletal injury. Musculoskeletal movement patterns (7), decreased core stability (16), and balance deficits (8,29) have all been associated with increased injury risk. A screening system that identifies individuals with muscle imbalance, decreased core stability, and balance deficits resulting in aberrant movement patterns may benefit the future of injury prevention. Screening tools used clinically for injury prediction are the Functional Movement Screen (FMS) (11) and the Y Balance Test (YBT) (1,31). The FMS is composed of 7 fundamental movements (deep squat, hurdle step, inline lunge, shoulder mobility, straight leg raise, trunk stability push-up, and rotary stability), each scored on a 4-point ordinal scale based on the participant s performance or presence of pain (11). A composite score (0 21) is calculated by summing the 7 movement pattern scores. A composite score #14 has been reported in specific populations to identify individuals at increased risk of sustaining musculoskeletal injury (7,10,20,28). The YBT is an instrumented version of the Star Excursion Balance Test (SEBT) (31). The YBT and SEBT measure dynamic balance during single leg stance and require the 2296

2 the strength, proprioception, and flexibility (31). The YBT requires single leg stance while reaching with the opposite leg in anterior (ANT), posterolateral (PL), and posteromedial (PM) directions. A composite score is then calculated by summing the distance reached in the 3 reach directions (ANT, PL, and PM) relative to leg length. The YBT has been reported to predict injury based on overall reach performance (different cutoff points based on the sample) (8,23,32) and reach asymmetry between limbs (anterior reach difference greater than 4 cm) (32,36). The FMS (20,21), SEBT (8,32), and YBT (9,36) have all been reported to predict injury in athletic populations; the FMS has also been reported to predict injury in firefighters (7) and in military personnel (25). Normative FMS values have also been reported in general active adult populations (30,35), but no association with injury is known for this population. Normative values on the SEBT have been established in young adult and middle-aged women (4), whereas YBT normative values have been established in healthy military members (38). Overall, studies conducted using FMS or YBT in the general population are limited. Thus, how performance of the general population compares with that of athletes remains unknown, despite the fact that many members of the general population participate in regular physical activity. Although many members of the general population may never be screened before participation in activity, these individuals still engage in recreational and athletic activities. Keating et al. (18) reported that a majority of college students (50 70%) are physically active. For the 30 50% who are sedentary, Keating et al. (18) emphasized the importance of interventions to increase levels of physical activity among college students. Whether an athlete or a physically active student, an effective screen for injury risk may be crucial. In fact, the American Physical Therapy Association (APTA) advocates an annual musculoskeletal screening visit with a physical therapist (PT) to prevent injuries associated with activities of daily living and SREs in an active population (3). Although normative values for FMS (30,35) and SEBT (4) have been established in the general population, research in this area is still limited. The majority of existing research has focused on normative values established in athletic samples. It is unknown if the results of existing research in athletic samples can be appropriately applied to members of the general population. No study to date has directly evaluated a comparison between normative values established in athletes and members of the general population. Thus, to better understand the application of the FMS and the YBT to general college students, this study examined whether or not general college students performed similarly to student-athletes on the FMS (composite and movement pattern scores) and the YBT (composite and reach directions). If general college students perform similarly to studentathletes, then existing literature in athletes on the FMS and YBT may be appropriately applied to general college students. If not, further research may be warranted. Based on the intense skill-specific training regimen of many athletes, it was hypothesized that student-athletes would score higher than general college students on FMS composite and movement pattern scores and that student-athletes would score higher than general college students on YBT composite score and reach directions. METHODS Experimental Approach to the Problem To test the hypothesis and determine whether or not student-athletes scored higher than general college students on the FMS and YBT, performance between groups was compared on both screens. The independent variable was participant group (student-athlete vs. general college student), and the dependent variables were performance as determined by score on the FMS and YBT. In this cross-sectional study, an injury-free, healthy college cohort between the ages of 18 and 24 ([mean 6 SD] years) was screened using the FMS and YBT. This mixed cohort comprised student-athletes (n = 167) and general college students (n = 103) from the same university. Composite and movement pattern scores were assessed for the FMS, whereas composite and reach direction scores were assessed for the YBT. Subjects Of 270 total participants (151 women and 119 men), 167 were Division I student-athletes and 103 were general college students. Student-athletes scores were obtained from previous research that investigated FMS, YBT, and noncontact injury risk during season (36,40). These athletes were screened during the summer of 2011 and were followed throughout the season to assess prevalence of injury, with results reported by Smith et al. (36) and Warren et al. (40). General college students were recruited and screened during the Fall and Spring semesters from the same university. All procedures were approved by Northern Arizona University Institutional Review Board, and participants signed an informed consent document before participation. The participants, all 18 years of age and older, received full explanation of the nature, purpose, and risks of the study and were given the opportunity to ask any questions. After the explanation, the participants signed the informed consent approved by the Institutional Review Board at Northern Arizona University before participation in the study. General college students included in this study were years old, currently enrolled in an undergraduate or graduate course of study. Potential participants were excluded because of current injury or illness limiting participation in physical activity as determined by screening using the Physical Activity Readiness Questionnaire (PAR-Q) (5). Any concerns were screened by a licensed PT. Student-athletes included in this study were years old and current members of Division I athletic teams (men s and women s basketball, tennis, cross-country, and track; women s cheer VOLUME 29 NUMBER 8 AUGUST

3 FMS, YBT in Student-Athletes and General Students and dance, golf, swimming and diving, volleyball, and soccer; and men s football). All were cleared for sport participation by the team physician during the preparticipation examination. Student-athletes were excluded from this study with any current musculoskeletal injury that would limit participation in data collection; this was determined by a PT or an athletic trainer (ATC) before participation. Procedures FMS (Functional Movement Systems Inc., Chatham, VA, USA) and YBT (Move2Perform, Evansville, IN, USA) testing were completed in a single testing session; a standard testing method and scripts were followed for both FMS (11) and YBT (1). The participants were tested at a time convenient for them. The subjects were permitted to engage in normal daily routines without limitations. All raters were trained before administration of the tests. FMS raters completed a 2-hour training session using materials from the creators of the FMS (11). The raters previously showed good interrater reliability (Intraclass Correlation Coefficient [ICC] = ) and intrarater reliability (ICC = ) (37). Testers administering the YBT completed an online training program from the developers of the test (1). Previous research has shown that the YBT also has good to excellent interrater reliability ( ) and intrarater reliability ( ) with standardized equipment and testing protocol (31). Participants wore self-selected athletic shoes and athletic clothes for the FMS; shoes and socks were removed for the YBT. In the FMS, standard testing procedures were used (11). Each participant performed 7 fundamental movements (deep squat, hurdle step, inline lunge, shoulder mobility, straight leg raise, trunk stability push-up, and rotary stability). Additionally, the following 3 clearing tests (positive or negative based on the presence of pain) were used: shoulder impingement test clearing for shoulder mobility, spinal extension test clearing for trunk stability push-up, and spinal flexion test clearing for rotary stability. For each movement, a score of 0 was given if there was pain during any portion of TABLE 1. Demographic characteristics for the student-athletes and general college students. Student-athletes (n = 167) General college students (n = 103) Age (y) (mean 6 SD) ,0.001* Sex (% male) * Body mass index (kg/m 2 ) * (mean 6 SD) FMS (% #14) 53.9% 57.3% 0.59 *p # 0.05 between student-athletes and general college students. the 2298 the movement or with the corresponding clearing test. A score of 1 indicated that the participant was unable to complete the movement, 2 represented compensation in completing the movement, and 3 signified correct completion without compensation. Asymmetry was noted in 5 movement patterns performed bilaterally: hurdle step, inline lunge, shoulder mobility, active straight leg raise, and rotary stability. For example, the right inline lunge was performed completely without compensation, whereas the left side could not maintain balance during the movement. Asymmetry between each side was recorded by scoring the right inline lunge as a 3 and the left as 1. The lowest score of the movements performed bilaterally was used to calculate the total. All 7 movement pattern scores were summed to determine the FMS composite score with an overall range of As per the FMS instructions (11), up to 3 trials of each movement were allowed, with the best score of the 3 trials recorded on a score sheet. In the YBT, each participant was allowed 4 6 practice trials. Research assessing the learning curve in YBT practice trials shows an initial increase in distance followed by a plateau when longest reach distance is attained (27,34). Robinson and Gribble (34) found longest reach distances plateaued at 4 trials. In this study, 6 trials were allowed if a participant requested more practice or if large improvements in reach distance were noted on the fourth attempt, to ensure the learning plateau (27) was reached. After practice trials, data were collected for the best of 3 trials for each direction (ANT, PL, and PM) on each leg (1,9,31). A composite score was then calculated by taking the average between right and left leg for the best reach distance in each direction and then summing the averages of the 3 reach directions (ANT, PL, and PM). The score was then expressed relative to limb length by calculating reach distance divided by right-limb length (i.e., inferior, anterior, superior, iliac spine to inferior medial malleolus) multiplied by 100 (36). p Statistical Analyses Demographic variables between student-athletes and general college students were assessed as mean values with independent t-tests for differences for continuous variables (age and body mass index [BMI]) and proportions and chi-square for categorical variables (sex and FMS composite score dichotomized). The independent variable for all multivariable analyses was participant group (student-athlete vs. general college student). Composite scores for FMS and YBT as the dependent variables were analyzed using

4 the TABLE 2. FMS and YBT composite scores between student-athletes and general college students overall, in men, and in women.* Composite score Student-athletes (n = 167) (mean 6 SE) General college students (n = 103) (mean 6 SE) p Mean difference between student-athletes and general college students 95% CI for the difference between the two mean values FMS Overall to 0.6 Men to 0.9 Women to 1.2 YBT Overall 101.8% 6 0.7% 97.0% 6 0.9%,0.0001z 4.8% 2.6 to 7.0% Men 102.8% 6 1.0% 99.5% 6 1.8% % 20.6 to 7.2% Women 100.6% 6 0.8% 95.1% 6 0.9%, % 3.1 to 7.9% *FMS = Functional Movement Screen; YBT = Y Balance Test; CI = confidence interval; % = reach distance expressed as percent of limb length. N = 270 overall (119 men and 151 women). FMS composite score (0 21) is the sum of its 7 movement pattern scores, each scored 0 3. zp # 0.05 between student-athletes and general college students in the overall sample. p # 0.05 between student-athletes and general college students in female participants. general linear models (GLMs) to assess differences between the 2 groups. FMS movement pattern differences between groups were analyzed using logistic regression; the dependent variable was the ordinal score for the FMS movement pattern with scores of 0 and 1 combined to 1. Differences in YBT between groups reach distances were analyzed using GLM. Asymmetry differences between groups for YBT reach distances in each direction (ANT, PM, and PL) between right and left leg on the YBT were analyzed by logistic regression. The dependent variable was the presence of significant asymmetry (,4 cm vs. $4 cm). Ninety-five percent confidence intervals were calculated for the mean performance values and for the difference between the mean values of the 2 groups (student-athletes vs. general college students). All analyses were conducted with the entire sample (adjusted for age, sex, and BMI) and sex stratified (adjusted for age and BMI). Results were considered statistically significant for p # SAS (version 9.2; SAS Institute, Inc., Cary, NC, USA) was used for all data management and analysis. RESULTS TABLE 3. Statistical differences between student-athletes and general college students based on sex in performance on the Functional Movement Screen movement patterns.* FMS movement pattern Overall (N = 270) Men (n = 119) Women (n = 151) Deep squat z Hurdle step Lunge Straight leg raise Shoulder mobility Push-up Rotary stability *All values listed in the table are p values referring to the statistical difference in performance between student-athletes and general college students on each movement pattern. p # 0.05 between student-athletes and general college students in the overall sample. zp # 0.05 between student-athletes and general college students in female participants. Demographic analysis and anthropometric data showed a significant difference between student-athletes and general college students for age, sex, and BMI (Table 1). Studentathletes were younger (p, 0.001) and heavier (p = ) than the general college students. There were more men, proportionally, among student-athletes than general college students (p = ). There was no significant difference (p = 0.59) between student-athletes and general college students for the percent that scored below or equal to 14 on the FMS (Table 1). No difference was found in FMS composite scores between student-athletes and general college students in the overall sample, in men, or in women VOLUME 29 NUMBER 8 AUGUST

5 FMS, YBT in Student-Athletes and General Students TABLE 4. Comparison of YBT reach distances overall, in men, and in women between student-athletes and general college students.* Student-athletes (n = 167) (% limb length 6SE) General college students (n = 103) (% limb length 6SE) p Mean difference between student-athletes and general college students (% limb length) 95% CI for the difference between the two mean values (% limb length) Anterior Overall z to 4.9 Men to 6.8 Women to 4.7 Posteromedial Overall z to 8.3 Men to 8.4 Women , to 10.1 Posterolateral Overall ,0.0001z to 8.2 Men to 8.3 Women , to 9.9 *YBT = Y Balance Test; CI = confidence interval. N = 270 overall (119 men and 151 women). zp # 0.05 between student-athletes and general college students in the overall sample. p # 0.05 between student-athletes and general college students in female participants. (Table 2). For FMS movement patterns, there was a significant difference in deep squat in women (p = 0.01) and in deep squat for the overall sample (p = 0.005). In both cases, student-athletes scored higher than general college students (Table 3). Student-athletes scored higher than general college students in YBT composite scores in the overall sample and among women (p, for both). There was no difference (p = 0.12) in YBT composite scores among men. (Table 2). In analysis of YBT reach distances, a significant difference was found in all directions (ANT, PM, and PL) between student-athletes and general college students in the overall sample and in women but not in men (Table 4). Student-athletes scored significantly higher than general college students overall (p, for all directions) and in women (p, 0.01 for all directions). There was no significant difference between male student-athletes and general college students (p $ 0.08 for all directions). (Table 4). No difference was found for asymmetry in any YBT reach direction in the overall sample, in men, or in women (p $ 0.05 for all directions) [data not shown]. DISCUSSION This study examined whether or not general college students performed similarly to student-athletes on the FMS (composite and movement pattern scores) and the YBT (composite score and reach directions), with the hypotheses that student-athletes would score higher than general college students in FMS composite and movement pattern scores, and that student-athletes would score higher than general college students in YBT composite score and reach directions. Results show no difference between student-athletes and general college students in FMS composite scores, rejecting this hypothesis. Among FMS movement pattern scores, the deep squat was significantly different in the overall sample and in women, with student-athletes scoring higher than general college students as hypothesized. Likewise, in support of the original hypothesis, student-athletes scored higher than general college students on the YBT in both composite score and reach directions in the overall sample and among women. However, no differences in YBT composite score or reach directions were found in men, again rejecting the hypothesis. There was no difference in FMS composite scores between student-athletes and general college students, rejecting the original hypothesis. Previously, Schneiders et al. (35) established a mean FMS score for a young (age: years), active, general population of with no statistically significant difference in scores between men and women. Perry and Koehle (30) established as a mean FMS score among men and in women in the general population aged years. A higher level of exercise participation was associated with a higher FMS composite score. The lower scores in the study by Perry et al. may be attributed to the fact that the participant pool in the 2 studies likely differed in activity level. Schneiders et al. (35) included individuals who participated in both competitive and recreational physical activity, with some the 2300

6 the participants drawn from sports clubs. Perry and Koehle (30) drew participants from a multidisciplinary health care clinic. Mean scores found in this study were lower than these previously established norms, with student-athletes and general college students scoring and , respectively. It should be noted that 1 point, gained or lost over the course of 7 different movement patterns, is not a large difference out of 21 possible points. Multiple studies have reported higher mean scores among military personnel ( and ) (17,28), professional football players ( and ) (20,21), runners ( ) (26), and Gaelic field athletes ( ) (14). However, other studies have reported FMS scores lower than those found in this study. Cowen (12) found a mean score of among firefighters, whereas Kiesel et al. (19) found a mean score of among football linemen and among football non-linemen. Cowen (12) and Kiesel et al. (19) both found that FMS scores increased after exercise-based intervention. This suggested that level of activity impacted scores, and scores may be improved with training for sport participation. The findings of this study indicate that general level of activity may be more important to FMS score than sport-specific training, as there was no difference in performance of student-athletes and general college students. It must also be noted that mean scores in this study were both very close to the pre-established injury cutoff point of 14 (7,10,20,28). As presented in Table 1, a majority of both student-athletes (53.9%) and general college students (57.3%) scored at or below 14 on the FMS. This may indicate a need for specific exercise-based training to increase FMS scores and limit the risk of injury among these participants, studentathletes and general college students alike. Among FMS movement pattern scores, only the deep squat movement pattern was significantly different between student-athletes and general college students, with studentathletes scoring higher than general college students as hypothesized. This difference was seen in the overall sample and among women. This difference may be attributed to sport-specific, intensive strengthening and training among female athletes, not replicated in the regular activities of general college women. As there was no difference in deep squat performance among men, the difference in the deep squat in women accounts for the difference overall. This may indicate that regular activity undertaken by general college men provides them greater squat-specific strength than does the regular activity of general college women. Previous research by Grygorowicz et al. (15) conducted in female soccer players also found a difference in deep squat performance based on level of sports skill. However, differences in rotary stability, inline lunge, and straight leg raise were also found to exist between groups in the study by Grygorowicz (15). As such differences were not found in this study, further research may be warranted in this area, specifically among women. In this study, student-athletes scored higher than general college students on YBT composite scores in the overall sample and in women but not in men. The same was true for all YBT reach directions. Thus, for both composite scores and reach directions, findings of the study support the original hypothesis for female participants and for the overall sample, while rejecting the original hypothesis for male participants. These findings indicate that the overall difference between cohorts can be explained by the difference in women. Previous literature has suggested that neuromuscular differences between men and women may be partially responsible for the increased prevalence of injury in female athletes (13,22,33). A study by Thorpe and Ebersole (39) found that the SEBT was sensitive to level of training in female soccer athletes, with reach distance significantly greater for soccer athletes than for non-soccer participants. The study found greater lower extremity strength among soccer athletes when compared with non-soccer participants (39), which may possibly carryover to greater neuromuscular control through the extremities as well. Bressel et al. (6) found differences in dynamic balance performance among female athletes based on sport. In this study, female basketball players were found to demonstrate less dynamic balance as measured by the SEBT when compared with female gymnasts or female soccer players. No difference was found between gymnasts and soccer players suggesting that differences in balance performance may be the result of uniquely different sensorimotor challenges posed by each sport (6). It is possible that the YBT testing challenged the sensorimotor system (6) more in the general college women than it did in the female athletes, resulting in shorter reach distances among the general college women. Thus, appropriate training for neuromuscular and sensorimotor control may be necessary to YBT performance. General college men may achieve more appropriate training from regular activities than general college women. Thus, specific training activities must be emphasized particularly among women. One strength of this study is the large sample size including student-athletes from 12 different Division I college sports teams and general college students from the same university. Furthermore, the study used 2 screening tools that are relatively easy to administer and could easily be incorporated into a preparticipation screen for individuals at any level of activity. Both screens can be administered quickly, making them a practical addition to a preparticipation screen. In this study, the FMS was administered in minutes, whereas the YBT was administered in 4 5 minutes. All raters were trained before administering the screens, and FMS raters showed high levels of intrarater ( ) and interrater ( ) reliability (37). Likewise, standard validated testing protocols were followed for the YBT and the FMS, making this study easily applicable and reproducible in future research and in clinical practice. This study adds to the existing body of literature in that it is the first of its kind to directly compare VOLUME 29 NUMBER 8 AUGUST

7 FMS, YBT in Student-Athletes and General Students the performance of athletes to that of members of the general population, all evaluated in the same setting by the same raters. The majority of existing literature has been conducted on athletes; limited studies have examined the general population, and those that have included general population have not accounted for how performance compares with that of athletes. This study bridges this gap. Limitations of this study must also be noted. A convenience sample was used in this study. Adding more variety of participants would increase the external validity of this research. Although YBT testers were trained before administration of the test, individual reliability in administering the test was not formally assessed for YBT. In conclusion, the results of this study show that the FMS composite scores were not different between groups. Female student-athletes scored higher than female general college students on the deep squat. Furthermore, research should examine performance differences in the deep squat between female athletes and women in the general population. As there was no difference in male performance, the YBT is expected to be equally effective in screening male studentathletes and general college men. However, student-athletes scored higher than general college students among women and in the overall sample, indicating that existing research conducted in athletes may not apply equally to general women or mixed groups. Furthermore, research should examine the use of the YBT to screen general college women, as population specific norms and risk cutoff scores should be established. PRACTICAL APPLICATIONS As no difference was found in performance between studentathletes and general college students on the FMS composite score, existing research on the FMS composite score in athletic populations is expected to apply to a general college population for purposes of preparticipation screening, injury prediction, etc. As there was no difference in performance between male student-athletes and male general college students on the YBT, existing research on the YBT in male athletic populations is expected to apply equally to general college men for the purposes of preparticipation screening, injury prediction, etc. ACKNOWLEDGMENTS This research was performed under an intramural research grant award from Northern Arizona University. The authors declare there is no conflict of interest. The results of this study do not constitute endorsement of the product by the authors or the NSCA. REFERENCES 1. Y Balance Test. 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