Functional movement screen norms

“However, the common misconception that screens by themselves can prevent injury has been challenged because they only provide individual information that is often based on standardized exercise recommendations, and may or may not suit an athlete’s specific needs”

Screening tools can be helpful in terms of setting up expectations and who should be monitored over time, but so far a screening tool is not a good measure of who will get injured.

For instance, I’ve written extensively about the Start Back Screening Tool, but this tool is used after a person experiences an injury or pain. It doesn’t attempt to predict who will experience an injury or pain.

“Assessing basic fundamental movement provides an opportunity to create a more individualized training program that focuses on changing or modifying movement patterns, instead of focusing on the rehabilitation of specific joints and muscles.”

Assessing basic fundamental movements…let’s stop here. Who gets to judge basic fundamental movement?

If we listen to Paul Chek then we would include walking, running and pulling movements into an assessment.

If we listen to USAW, then the screen looks eerily similar to the movements that will be performed in sport, only with less speed and weight.

The goal of screening an athlete, or anyone for that matter, is to determine if the person has characteristics that would prevent them from participating in their life activities due to injury.

I also believe that we can modify movements and change motor patterns, but only to an extent.

For example, someone with biomechanical issues, such as a different angled neck of the femur, long femur or short torso will not squat/lunge in the same fashion as those with different levers.

Meaning that we can stretch the ankle until we are blue in the face, but at some point a person just runs out of dorsiflexion due to joint mechanics.

“The FMS (TM) was developed as a comprehensive pre-participation and pre-season screen, and consists of seven tests/movements which challenge an individuals ability to perform basic movement patterns that reflect combinations of muscle strength, flexibility, range of motion, coordination, balance, and proprioception.”

This sounds great! Unfortunately “pre-participation” in curling requires different mobility, strength and balance when compared to wrestling or archery. We can’t just hang our hat on a one-size-fits all approach.

“Five of the seven FMS (TM) tests are scored separately for left and right sides, and can therefore be used to locate asymmetries which have been identified as an injury risk factor. An FMS (TM) specific cut-off value of 14 or below is suggested to indicate an elevated risk of injury”

I don’t have data for this, but some sports are inherently asymmetrical. Look at tennis, bowling, curling, baseball, golf and so many others…would we increase risk of injury by making these players symmetrical?

I know that there is follow-up research on the FMS stating that the asymmetries on the test are more predictive than the score cut-off, but I would like to see a specific study done on a mostly asymmetric sport, one that limits forward running, but maybe emphasizes lateral movement and only use of 1 arm or leg.

“…small sample size…ability to generalize this cut-off value to other sport and recreation participants may be limited”

The ability to generalize the results from one study is limited to the participant demographics within that study attempting to cite. For instance, the FMS (TM) has a cut-off score of 14, but this only applies to profesional football players. That’s a very narrow field, with which to apply the results.

“To date, there are no published normative values for score on the FMS (TM) to help sports physical therapists, coaches, and athletic trainers interpret the raw data collected during testing”

Typically, we would see normative data or studies performed before we see abnormal, or predictive of injury studies, performed.

An example would be this:

If the norms for the FMS is 15, but injury risk increases at 14, there is a very narrow window of error on the tester’s ability that could take one from healthy/normal to high risk for injury.

“convenience sample…approximately 200 females and males…between 18 and 40 years…recruited from tertiary population”

“Exclusion criteria…use of mobility aid or prophylactic device, or if they had reported a recent musculoskeletal or head injury”

“Each participant was given three trials on each of the seven tests (deep squat, hurdle step, in-line lunge, shoulder mobility, active straight leg raise, trunk stability push up, and rotary stability)”

To be certain, I do like some of the movements in the screen, but I’m not sure if I like the scoring and I believe that the screen is limited in scope. Here is a video of Grey Cook describing the movement screen. I enjoyed the video and I included it for your viewing pleasure.

“The combined composite mean score on the FMS (TM) was 15.7 with a standard deviation of 1.9 and a median of 16.”

Let’s break this down. Many people, both Physical Therapists and personal trainers, were taught to use the cut-off score of 14 as a sign of dysfunction.

The mean (average score) was 15.7, but the standard deviation could actually place the average in the same range as someone considered dysfunctional. If this is the case, then this testing is not very specific for finding dysfunction because the norm is dysfunctional.

“31% of the participants, had a composite score of 14 or below which indicates a heightened risk of injury according to Keivel et al.”

One-third of normal-healthy people are considered dysfunctional based on this test. We can’t extrapolate (assume that data from one study can be used on other people that don’t fit the study from which we obtained the data).

We can’t state thy this population is at risk of injury because of their score. Just because they scored 14 on the test doesn’t mean that they are at a higher risk for injury. They are not professional football players and can not be held to the same standards.

“The cutoff score of 14 was determined in a study on 46 professional football players…used with caution. “

The reason it has to be used with caution is simple.

This test is purportedly used to determine if someone is as risk of injury.

The average person doesn’t put themselves through the same type of activities and stresses as a professional football player. They shouldn’t use the same testing procedure to determine if they are at the same risk of injury.

Link to article


Start Back Screening Tool

“Lifetime prevalence for LBP (low back pain) has been reported to be between 60% and 95% and 34% of the participants in a large population study in Norway reported to have had LBP last week”

These numbers are scary, but are consistent with other published research that notes about 80% of the population will have back pain at some point in life. Think of how lucky you would have to be to go an entire lifetime without having back pain based on these numbers?

It can happen, as I’ve seen patients in their 80’s with a first time occurrence of back pain.

The part that is sad for me, as a PT, is that less than 10% of these people will ever get in to see a PT for back pain.

“Due to the lack of diagnostic tests that can identify objective signs of the condition, most of the patients are characterized as having ‘non-specific LBP'”

If you’re not familiar with the numbers, it has been said that any diagnosis trying to name a specific tissue (disc herniation, arthritis, spondylisthesis, spinal stenosis etc) is only correct about 10% of the time. The more severe the diagnosis the more likely that the specific tissue is the correct diagnosis (such as a tumor, spinal cord injury, infection).

Because of this, a majority (90%) of back pain is just labeled as “non-specific low back pain”. The problem with this is that the treatment for a non-specific problem tends to be…non-specific.

Don’t get me wrong, a majority of back pain doesn’t need much treatment, if any at all, and tends to improve over the course of 6 weeks. Some pains from the back require a specific treatment and a treatment outside of this Specific treatment can worsen symptoms.

This means that we have to actually attempt to classify a patient’s presentation. Understand please that a classification is not a diagnosis but instead more of putting the symptoms into a non-specific “bucket” that most resemble that presentation. For instance, there could be a bucket for fast changing, slow changing and unchanging. There could be buckets for a primarily psychosocial component, chemical component or a bio mechanical component.

“Based on the SBT (Keele Start Back Tool) scores, patients can be categorized into three subgroups: patients with low, medium, or high risk for developing persistent LBP and activity limitations….the low risk group should receive minor attention from health professionals and self management strategies are recommended for these patients. The medium risk group should be offered physiotherapy. For the high risk group more psychologically informed interventions are recommended”

This statement may upset some of my colleagues in PT, but we aren’t always needed for patients that experience back pain. For instance, it is advocated to see a PT if you have pain lingering more than a couple of Days. I’m not sure I completely agree with this, as much back pain reduces spontaneously. The last thing you, as the patient should want is to pay for unneeded treatments. The last thing that I want to do as a PT is to take a patients money if I am not needed at that time.

Again, don’t get me wrong there is a group of patients, with back pain, that should be treated by a Physical Therapist. These patients will score higher on the Start Back Screening Tool.

With that said, it is important that the patient be classified correctly within the first 6 weeks of experiencing symptoms. Some research demonstrates an early classification is beneficial and others demonstrate that it should be done within 6 weeks of symptoms. The reason for this is that the patient may benefit from more psychologically informed interventions, which should be performed by someone with

“To be useful as a screening tool in physiotherapy practice, it is important that the SBT-scoring is reliable and that the allocation to risk groups reflects the severity of the patients back problems.”

There are two things that we look at in terms of performing testing. One, is the test valid. This means does the test actually tell us what we think it tells us.

The second thing is reliability. This means that if I have multiple therapist from different settings performing the same exact task, would I get similar or exact scoring if performed on the same exact patient by different therapists.

“The SBT consists of nine items; referred leg pain, comorbid pain, disability, bothersomeness, catastrophizing, fear, anxiety, and depression…. The total score range from 0 to9, with nine indicating worst prognosis. The last five items are summarized into a psychosocial sub scale with five as the maximal score, indicating high risk for development of chronic LBP”

For more information about scoring, I personally like to use the Shirley Ryan website of outcome measures found here.

“Patients with a total score of 0-3 are classified as low risk (minimal treatment, eg self-management strategies).

I use this tool frequently in PT. I rarely have patients score a 3 or less, but this may be because they are already filtered out by the physician in primary care.

I recently had a patient score a 3 and lo and behold his symptoms were abolished in 6 weeks without intervention.

It’s a small sample size, but it seems to match the research.

To summarize: the STarT Back Screening Tool is an option to utilize in practice in order to determine if a patient

1. Requires little/no intervention and will return to prior level of function (PLOF) through regression to the mean (time > interventions).

2. Requires PT/Rehab only

3. Requires a more psychologically intensive approach to care.

Click here for original research article.

STarT Back Screening tool revisited

“…changes in psychosocial risk factors during the course of treatment may provide important information for a patient’s long-term prognosis”

As professionals, we should be performing repeated assessments of patients during the plan of care (POC) and not waiting until the patient is ready for discharge (either because their benefits have been exhausted, the insurance company dictates that an assessment needs to be performed or the patient self-discharged). Performing repeated assessments throughout the POC allows us, as professionals, to understand if the patient is improving, worsening or remaining unchanged with care and to assist us in modifying the POC.

The STarT Back Screening Tool is one method of assessing psychosocial factors that may impede rehab potential.

“… repeated assessments during an episode of care can also provide valuable information about changes in a given variable that can be used for treatment monitoring”

Utilizing a standardized approach to assessing a patient will enable the professional (PT in my case) to determine if a patient is catastrophizing, losing hope, or requires the assistance of a more psychologically focused treatment approach.

“The STarT Back Tool (SBT) is a Screening questionnaire consisting of nine items related to physical and psychosocial statements that are used to categorize patients based on risk (low, medium, or high) for persistent LBP-related disability.”

Here is a copy of the tool in question.

“Wideman et al found that early changes in SBT scores were predictive of four month treatment related changes in several relevant psychological and clinical outcome measures.”

This is a little different than what is expected from an outcome tool. For instance, many tools are utilized to tell the clinician where the patient is at currently and if this patient Hs a risk of developing chronic pain.

When we utilize multiple scores instead of a standalone score, this is indicative of how a patient will progress over the course of time.

“all patients (in this study) were referred for physical therapy by a physician and did not seek physical therapy services through direct access… this setting was considered secondary care.”

This is an important topic. For instance, the previous blog post indicated that the tool gives us information when read minister over a 4-week time period. This indicates that there are changes that occur over the course of 4 weeks.

Many complaints of low back pain improve independently over the course of 6 weeks. If a patient is issued this test at the first visit and classified as low, medium or high, this may lead to an inaccurate classification. Seeing as this study issued the tool to patients in a secondary care (meaning that the patients were referred by a physician) indicates that the patient is not being seen within the first few days of injury.

“1. Aged 18-65 years,

2. Seeking physical therapy for LBP (symptoms are T12 or lower, including radiating pain into the buttocks and lower extremity), and

3. Able to read and speak English”

“treatment was not standardized or tracked in this study and was provided at the discretion of the physical therapist.”

This may also be an issue, as there is a newer study that indicates the treatment interventions may have a role in the patient’s scoring.

Please see the previous post about how to utilize this tool.

“…123 patients (84.2% of the entire sample) who completed the SBT at intake and 4 weeks…The percent of patients for each SBT risk category who were classified differently at intake and four weeks was 81.8% for SBT high risk, 76.0% for SPT medium risk and 11.3% for SBT low risk.”

This indicates that a patient’s initial score should be interpreted with caution because there is a high probability that it will change over the course of 4 weeks.

“most patients either improved (48.8%) or remained stable (40.6%) based on changes in SBT categorization.”

“Thirteen (10.6%) patients were categorized as worsened based on changes in SBT categorization, with six of those patients categorized as SB team high-risk at intake and four weeks later.”

This is interesting to me. Typically, in PT, a therapist will cite regression to the mean. This essentially states that given time the patient will transition from an extreme score towards a more moderate score. This doesn’t account for those that transition from a moderate score towards a more extreme score. To me, this indicates that the episode of care had an effect, albeit a negative effect, on this patient encounter.

Primary findings of this present study were as follows:

1. At over 4 weeks, approximately 11% of patients worsened SBT risk;

2. Clinicians should be less confident in the stability of an intake SBT categorization of high risk than that of medium and low risk;

3. Prediction of 6-month pain intensity scores was not improved when considering intake or 4-week change for SBT categorization; and

4. Prediction of 6-month disability scores was improved when considering intake, 4-week, and 4-week-change SBT categorization”

This indicates that the first measurement may not be a good indication of what will take place with the patient regarding disability over time and some patients can be made worse with therapy. We already knew the second part from previous blog posts.

Excerpts from:

Beneciuk JM, Fritz J, George SZ. The STarT Back Screening Tool for Prediction of 6-month Clinical Outcomes: Relevance of Change Patterns in Outpatient Physical Therapy Settings. J Orthop Sports Phys Ther. 2014;44(9):656-664.