10/16/2017. Background. Background. Impact of injury. An overview of movement screening in sport the good, the bad, and the ugly.

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1 10/16/017 An overview of movement screening in sport the good, the bad, and the ugly Moran RW, 1,4 Mason J, 1 Schneiders AG, Major K, 3 Sullivan SJ Health Care (Osteopathy), Unitec Institute of Technology. Discipline of Physiotherapy, Central Queensland University 3. Private Practice, Osteopathy 4. Centre for Health, Activity, and Rehabilitation. University of Otago Background Why we care about injury [apart from being paid] Recap: injury aetiology models Where movement quality might fit in injury aetiology Movement Screens What s available?, what claims? FMS focus Systematic review findings re FMS Overview good, bad, ugly Bigger picture movement screening in context Q + A Background Background Participation in physical activity is critical for the health of individuals and communities Compelling evidence that physical activity affords wide ranging health benefits [1-5] However Increasing participation in sport and exercise is inevitably associated with increasing exposure to risk of injury [6] A large proportion of injuries (especially in overuse) are preventable [7] Impact of injury Sport lower injury rates predict team success in professional sport [8-9] Military ( tactical athletes ) injury impacts on operational readiness [10] Society injury associated with disability, suffering, economic burden (direct costs of treatment, indirect costs of lost productivity) [11] When people are injured, they lose the many benefits of participating in exercise sometimes they don t return to pre-injury levels of participation 1

2 10/16/017 [1] Meeuwisse et al (007) [1] Meeuwisse et al (007) Movement quality Injury aetiology model What is movement quality? Poorly defined in the literature most research papers skirt around it A range of similar concepts and terminology in use Limited scholarly development some siloed thinking? eg physical literacy in physical education literature Edwards et al. Definitions, foundations and associations of physical literacy: a systematic review. Sports Med 017;47: Workload-injury aetiology model Windt & Gabbett, 016 Movement Quality An individual s ability to perform a specific movement task or pattern in an optimal manner - Kritz et al, 009 Which movement tasks? How many? How fast? Loaded? Unloaded? Both? etc Movement Quality An individual s ability to perform a specific movement task or pattern in an optimal manner - Kritz et al, 009 What does optimal mean? How to grade? How to record? etc Responses to these and similar questions have lead to

3 10/16/017 Bennett et al. J Strength Cond Res (10): >15 named screens Bennett et al. J Strength Cond Res (10): tasks in 9 categories Squat Hinge Lunge Pushing Pulling Abdominal bracing Mobility Balance Sport specific Bennett et al Multiple component musculoskeletal movement assessment tools: A systematic review and critical appraisal of their development and applicability to professional practice. J Strength Cond Res (10): of the 11 multiple component tests reviewed by Bennett et al identified predict injury risk as an assessment objective... Plenty of suggestion that these tests can play a role in injury prediction is it true? Most research interest = largest literature Incorporated into other derivative eg 9+ Most common screen? eg McCall et al BJSM 015 show widespread use in Euro premier football Well organised commercial basis, marketing 400 lb Shabani Nagoya Zoo, Japan Let s examine the FMS in some detail because: A measure of movement quality = Functional Movement Screen [13] Cook, 010 3

4 10/16/017 Each of the 7 movements is scored against standardised criteria: 4 point ordinal 0 = movement is painful Scoring = movement is incomplete = movement completed with [some] loss of balance, form, alignment 3 = movement is complete with no loss /1 Basic interpretation? Pain associated with any subtest? stop Magnitude of asymmetry left v right Kiesel et al (007) Started it all Which movements? basic to complex Ex Rx Composite score 14 and no asymmetries considered movement baseline no further intervention Odds of = large effect 4

5 Number indexed paper in PubMed 10/16/017 Conducted two systematic reviews Systematic Review 1 Reliability - Can practitioners agree on FMS findings? [boring but necessary] Systematic Review Prediction - Is the strength of association between FMS scores and injury risk sufficiently high to justify use as a prediction tool? [the sexy stuff] To critically appraise and synthesise studies investigating (1) rater reliability, and () the strength of association between FMS and subsequent injury PRISMA flow reliability = 1 studies Reliability: methodological diversity precludes meta-analysis Intra-rater reliability Can practitioners agree with themselves? moderate evidence of satisfactory intra-rater reliability Moran et al, 016 5

6 10/16/017 Inter-rater reliability Can different practitioners agree with each other? moderate evidence of satisfactory inter-rater reliability boring OK, so reliability is acceptable but can FMS predict injury? Quality of Cohort Studies Q-Coh [16] Jarde et al, 013 Satisfied Not Satisfied 1. Sample representativeness PRISMA flow validity = 3 studies. Comparability of groups 3. Exposure measure 4. Maintenance of comparability 5. Outcome measures 6. Attrition Proportion (%) of studies satisfying or not satisfying each QCoh domain 8 Good and Acceptable 16 low 6

7 10/16/017 Sport Military Smallest worthwhile effect - defined Odds Ratio 1.5 small effect Risk Ratio 1.1 small effect Area Under Curve (ROC) 0.70 Likelihood Ratio (change in post-test odds of ~ 15%) Inference is clear when lower limit of CI exceed these thresholds Military males meta-analysis Military female Strong evidence (3 high quality studies) of a small effect (RR lower limit CI >1.1) Limited 7

8 10/16/017 American Football Collegiate sports mixed cohorts Conflicting Conflicting High School sports mixed cohorts Basketball NBA and University Limited Limited Ice Hockey youth Running Limited Limited 8

9 10/16/017 Military male Strength of association between FMS composite score and injury? The overall level of evidence was limited or conflicting for a wide range of athletic populations including running, ice hockey, collegiate and high school sport, and professional or collegiate American football. Strong Football (soccer) In football (soccer), the magnitude of effect was unclear and there was moderate evidence to recommend against the use of FMS composite scores for the purpose of injury prediction. In football (soccer), the magnitude of effect was unclear and there was moderate evidence to recommend against the use of FMS composite scores for the purpose of injury prediction. Recent study of 44 Premier League teams shows ~80% use FMS for injury risk testing [17] McCall et al, 015 BJSM Main findings? The strength of association between FMS composite scores and subsequent injury was not sufficient to recommend use as an injury prediction tool in the sports reviewed. In male military personnel, there was strong evidence that the strength of association between composite score (cut-point 14/1) and subsequent injury was small. There was moderate evidence to recommend against the use of FMS composite scores as an injury prediction test in football (soccer). Likely not worthwhile as an injury prediction test (composite score) Objective good hard data Subjective good soft benefits Image: Neny Dee 9

10 10/16/017 Objective good hard data We tend to make rapid, falsely dichotomous judgements: Good v Bad Reminder: Systematic reviews often address very narrow and specific questions. We need to interpret the findings accordingly not beyond the findings Online response to our injury risk paper was interesting many using our narrow conclusion (composite scores) to broadly dismiss movement screening completely Adoption and rejection cycle is quite rapid in sports medicine (and physiotherapy generally) turbulent ride for ourselves and our patients Subjective good soft benefits Per the instructions, FMS offers a standardised, systematic approach that requires no technology [broomstick + roll of tape + measuring tape] For novice practitioners (and for students), the structure offered by movement screens are a solid starting point In strength & conditioning, basic movement screen (perhaps one with loading!) might usefully inform exercise prescription and help promote referral for pain that might otherwise be overlooked Having a standardized and systematic approach to identify the presence of painful movement ( pain face ) is useful when the athlete isn t a great historian (or doesn t admit minor injury/niggle) 1. Does the FMS composite score stack up as an index?. Have researchers and critics been playing a game of straw man? Question: Statistically speaking, is it OK to add all these separate tests up into a single composite score? 877 male 57 female US Marine officer candidates 147 male 143 female Chinese national Olympic games 88 male 88 female Collegiate athletes 10

11 10/16/017 Statistically speaking, is it OK to add all these separate tests up into a single composite score? No! components, don t add the 7 tests together No! components, don t add the 7 tests together Maybe? 1 or components FMS composite scores? just because we can, doesn t mean we should Are we refuting an argument that wasn t proposed by the FMS developers? Despite 4+ studies for prediction, only a few exploring these 11

12 10/16/017 Pain as a risk factor? Pain as a risk factor? Published Aug male soldiers over 6 months Alemany et al 017 (In Press) Functional Movement Screen: Pain versus composite score and injury risk. J Sci Med Sport Pain as a risk factor? Pain as a risk factor? +ve pain similar to poor composite score [in their sample] Moves away from movement quality altogether? Alemany et al 017 (In Press) Functional Movement Screen: Pain versus composite score and injury risk. J Sci Med Sport Just wondering if an athlete says yes, pain on that movement, then at some level, aren t we just saying I m already injured even if the athlete doesn t meet some formal definition for injury (eg time loss, or medical attention). L v R Asymmetry as a risk factor? L v R Asymmetry as a risk factor? 38 NFL players, pre-season 84 Collegiate athletes, ~1yr Asymmetry or a 1: RR =.73 (95% 1.36, 5.4) 1

13 10/16/017 FMS Psychological factors Load Monitoring Tissue resiliance Previous injury Rehab HRV 5 Ws Thinking about application who?, what? when? where? why? etc 13

14 10/16/017 Acknowledgements References Prof John Sullivan Prof Tony Schneiders Kate Major Jesse Mason 1. Blair SN. Effects of physical activity on cardiovascular disease mortality independent of risk factors. Physical Activity and Cardiovascular Health: A National Consensus. Champaign, IL: Human Kinetics 1997 : Siscovick D S, LaPorte RE, Newman JM. The disease-specific benefits and risks of physical activity and exercise. Public Health Rep 1985;100: Sothern M S, Loftin M, Suskind RM, et al. The health benefits of physical activity in children and adolescents: implications for chronic disease prevention. Eur J Pediatr 1999;158: Dias R C, Dias JM, Ramos LR. Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee. Physiother Res Int 003;8: Oka R K, De Marco T, Haskell WL, et al. Impact of a home-based walking and resistance training program on quality of life in patients with heart failure. Am J Cardiol 000;85: McBain K, Shrier I, Shultz R, et al. Prevention of sport injury 1: a systematic review of applied biomechanics and physiology outcomes research. Br J Sports Med 01;46: doi: /bjsm Verhagen EALM, van Mechelen W. Sport for all, injury prevention for all. Br J Sports Med 010;44(3):158. doi: /bjsm Hagglund M, Walden M, Magnusson H, et al. Injuries affect team performance negatively in professional football: an 11-year follow-up of the UEFA Champions League injury study. Br J Sports Med 013;47(1): doi: /bjsports Williams S, Trewartha G, Kemp SP, et al. Time loss injuries compromise team success in Elite Rugby Union: a 7-year prospective study. Br J Sports Med 016;50(11): doi: /bjsports Lincoln AE, Smith GS, Amoroso PJ, Bell NS. The natural history and risk factors of musculoskeletal conditions resulting in disability among US Army personnel. Work. 00;18: Hespanhol Junior LC, van Mechelen W, Verhagen E. Health and economic burden of running-related injuries in Dutch trailrunners: A prospective cohort study. Sports Med 016:1-11. doi: /s Meeuwisse WH, Tyreman H, Hagel B, et al. A dynamic model of etiology in sport injury: the recursive nature of risk and causation. Clin J Sport Med 007;17(3):15-9. doi: /JSM.0b013e318059a Cook G, Burton L, Hoogenboom BJ, et al. Functional movement screening: the use of fundamental movements as an assessment of function - part 1. Int J Sports Phys Ther 014;9(3): Kiesel K, Plisky PJ, Voight ML. Can serious injury in professional football be predicted by a preseason functional movement screen? N Am J Sports Phys Ther 007;(3): van Tulder M, Furlan A, Bombardier C, et al. Updated method guidelines for systematic reviews in the Cochrane collaboration back review group. Spine 003;8(1): doi: /01.BRS AF 16. Jarde A, Losilla J-M, Vives J, et al. Q-Coh: A tool to screen the methodological quality of cohort studies in systematic reviews and metaanalyses. Int J Clin Health Psychol 013;13(): doi: /S (13) McCall A, Carling C, Davison M, et al. 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. Br J Sports Med 015;49(9): doi: /bjsports