Multicomponent Musculoskeletal Movement Assessment Tools: A Systematic Review and Critical Appraisal of Their Development and Applicability to Professional Practice

The Development and Content of Movement Quality Assessments in Athletic Populations: A Systematic Review and Multilevel Meta-Analysis

BACKGROUND

Despite their prominence in the sport and human movement sciences, to date, there is no systematic insight about the development and content of movement quality assessments in athletic populations. This is an important gap to address, as it could yield both practical and scientific implications related to the continued screening of movement quality in athletic contexts. Hence, this study aimed to systematically review the (i) developmental approach, (ii) movements included, (iii) scoring system utilised, and (iv) the reliability of movement competency assessments used in athletic populations.

METHODS

Electronic databases (SPORTDiscus, MEDLINE, CINAHL, Web of Science, Scopus) were searched for relevant articles up to 12 May 2023. Studies were included if they reported data about the developmental approach, movements included, scoring system utilised and reliability of assessment in an athletic population. A modified Downs and Black checklist was used to measure study quality.

RESULTS

From a total of 131 identified studies: (i) 26 (20%) described the developmental approach of an assessment; (ii) 113 (86%) included descriptions of the movements included; (iii) 106 (81%) included a description of scoring system and criteria; and (iv) 77 (59%) studies included reliability statistics. There were 36 assessments identified within these studies, comprising 59 movements in total. Each assessment scored movement quality through a Likert or binary classification system.

CONCLUSION

First, the results demonstrate that choosing an appropriate movement quality assessment in an athletic population may be a complex process for practitioners as the development approach, movements included and scoring criteria vary substantially between assessments. Second, academics could use these results to help design new assessments for novel applications that meet rigour and reliability requirements. Third, these results have the potential to foster guidelines of use for the reliable assessment of movement quality in athletic populations.

Relationship Between Movement Quality and Physical Performance in Elite Adolescent Australian Football Players

ABSTRACT

Bennett, H, Fuller, J, Milanese, S, Jones, S, Moore, E, and Chalmers, S. The relationship between movement quality and physical performance in elite adolescent Australian football players. J Strength Cond Res XX(X): 000-000, 2020-The assessment of movement quality is commonplace in competitive sport to profile injury risk and guide exercise prescription. However, the relationship between movement quality scores and physical performance measures is unclear. Moreover, whether improvements in these measures are associated remain unknown. Over a 4-year period, 918 individual elite adolescent Australian Rules Footballers completed the Functional Movement Screen (FMS) and physical performance testing (5- and 20-m sprint, vertical jump, planned agility, and 20-m shuttle run test), allowing the analysis of relationships between FMS parameters and performance measures. In addition, 235 athletes completed testing over 2 consecutive years, allowing the analysis of relationships between changes in these outcomes. Small associations were observed between FMS composite score, hurdle step performance, in-line lunge performance, trunk stability push-up performance, rotary stability, and measures of speed, power, agility, and aerobic fitness (ρ = 0.071-0.238). Across consecutive seasons, significant improvements were observed in the deep squat subtest (d = 0.21), FMS composite score (d = 0.17), and 5- (d = 0.16) and 20-m sprint times (d = 0.39). A negative association between change in rotary stability and change in jump height (ρ = -0.236) from one season to the next was detected. Results suggest FMS scores have limited relationships with measures of performance in footballers. To optimize athletic performance, once acceptable movement capabilities have been established, training should not prioritize improving movement quality over improvements in strength, power, and change of direction ability.

Active straight leg raising (ASLR) competence improves with reverse-ASLR exercises and not repeating ASLR exercises

In the Functional Movement Screen (FMS), a subgroup of those with a score of 1 due to limitations in the active straight leg raising (ASLR) but not in the passive straight leg raising is considered to have a stability or motor control dysfunction (SMCD). The FMS proposes the use of the movements in a reverse pattern to improve FMS scores. The aim of this study was to investigate whether the reverse pattern of the ASLR (reverse-ASLR) was more effective than repeating the ASLR to improve the FMS score in participants with the FMS ASLR score of 1 due to the SMCD (ASLR-1-SMCD). A two-armed randomized controlled trial was conducted in individuals with the ASLR-1-SMCD. The intervention was either the reverse-ASLR or the ASLR exercise on both sides at home for a month followed by a 1-month wait-and-see interval, wherein the primary outcome measure was the right FMS ASLR score. Forty participants were randomized to the ASLR exercise group (n=20) or the reverse-ASLR exercise group (n=20). The Fisher exact test demonstrated a statistically significant difference (P=0.020) in the proportion of those with FMS ASLR score improvement to a score of 2 (ASLR exercise group, one; reverse-ASLR exercise group, eight) at follow-up 1, but no significance (P=0.106) at follow-up 2 (ASLR exercise group, none; reverse-ASLR exercise group, four). This study indicated that the reverse-ASLR exercise was more effective than repeating the ASLR exercise in order to improve the ASLR score among individuals with the ASLR-1-SMCD.

DEEP NECK FLEXORS IMPACT RECTUS ABDOMINIS MUSCLE ACTIVITY DURING ACTIVE STRAIGHT LEG RAISING

Background

Active straight leg raising (ASLR) is commonly performed to test fundamental movement competency. Head control or positioning can affect the abdominal muscle activity during movements.

Purpose

To investigate whether abdominal muscle activity differs when the head is extended or when deep neck flexor (DNF) muscles are selectively activated during the ASLR.

Study Design

Cross-sectional.

Methods

Participants were included based on the following criteria: 1) age>17 years; 2) no spinal or lower extremity pain in the prior month; 3) the vertical line of the malleolus in an elevated the lower limb resides below the knee joint line of a non-moving lower limb during ASLR and above during a passive straight leg raising in each lower limb; and 4) no history of diagnosed spinal deformities or central nervous system disorders. Participants with > 39% reference voluntary contraction in the sternocleidomastoid muscle during the craniocervical flexion test (CCFT) of 24 mmHg target were excluded from the analyses. Right ASLR was repeated in each of the following three head conditions in a random order: 1) neutral head position, 2) head extended by 25 °, and 3) CCFT maintained with a 24 mmHg target. Among the three head conditions, the relative latency for the onset of the right rectus femoris (RF) muscle during the right ASLR and the muscle activity amplitude for 50ms were compared after the onset of RF muscular activity in the following muscles: left rectus abdominis (RA), bilateral external obliques, bilateral internal obliques, and left gluteus maximus muscles.

Results

Data from 31 participants (21 women and 10 men, mean age=22.5 years) were analyzed. The relative latency of the left RA (Hedges' g = 0.39, p=.038) was higher in the CCFT condition (mean±SD=112.1ms±86.0ms) than that in the neutral head condition (82.9ms±58.6ms). However, no difference (all p>.05) was observed in other measures between the groups.

Conclusion

In people with impaired movement competency in ASLR, head extension did not alter the abdominal muscle activities in ASLR. However, selective activation of the DNF muscles delayed the onset of RA muscle activity during the ASLR.

Level of Evidence

4.

Automated classification of movement quality using the Microsoft Kinect V2 sensor

Practitioners commonly perform movement quality assessment through qualitative assessment protocols, which can be time-intensive and prone to inter-rater measurement bias. The advent of portable and inexpensive marker-less motion capture systems can improve assessment through objective joint kinematic analysis. The current study aimed to evaluate various machine learning models that used kinematic features from Kinect position data to classify a performer's Movement Competency Screen (MCS) score. A Kinect V2 sensor collected position data from 31 physically active males as they performed bilateral squat, forward lunge, and single-leg squat; and the movement quality was rated according to the MCS criteria. Features were extracted and selected from domain knowledge-based kinematic variables as model input. Multiclass logistic regression (MLR) was then performed to translate joint kinematics into MCS score. Performance indicators were calculated after a 10-fold cross validation of each model developed from Kinect-based kinematic variables. The analyses revealed that the models' sensitivity, specificity, and accuracy ranged from 0.66 to 0.89, 0.58 to 0.86, and 0.74 to 0.85, respectively. In conclusion, the Kinect-based automated movement quality assessment is a suitable, novel, and practical approach to movement quality assessment.

Earlier onsets in internal oblique and gluteus maximus muscles during leg raising in Functional Movement Screen score 3 than score 1

Active straight leg raising (ASLR) is a fundamental test and used in the Functional Movement Screen (FMS). In the ASLR of the FMS, one subgroup performs the movement correctly without any compensation (ASLR-3), whereas another subgroup has limitations in ASLR but not the passive straight leg raising (ASLR-1-SMCD). We aimed to investigate whether abdominal muscle activities in ASLR are different between individuals with ASLR-1-SMCD and ASLR-3. The relative latency of the onset of the following muscles to the right rectus femoris muscle during the right ASLR and the amplitude of activity in the following muscles for 50 msec after the onset of rectus femoris muscle activity were compared: left rectus abdominal, bilateral external oblique, bilateral internal oblique, and left gluteus maximus muscles. Data of 17 participants with ASLR-3 and 34 participants with ASLR-1-SMCD, whose sex ratio was matched to the ASLR-3 group, were analyzed. Those with ASLR-1-SMCD had statistically significant delays in the relative latency of the right internal oblique muscle (46.32±70.83 msec) and left gluteus maximus muscle (100.36±75.40 msec) muscles compared with those with ASLR-3 (right internal oblique muscle=9.75±23.07 msec, left gluteus maximus muscle=57.50±36.89 msec). However, the difference in the amplitude of activity in any muscles was not significant. The ASLR-1-SMCD group had greater relative latency of the onset of right internal oblique muscle and left gluteus maximus muscle to the onset of the right rectus femoris muscle during the right ASLR compared with the ASLR-3 group.

Greater Fitness Is Associated With Improved Functional Movement Characteristics in Explosive Ordnance Disposal Technicians

Hernández, LM, Coffin, SD, and Taylor, MK. Greater fitness is associated with improved functional movement characteristics in explosive ordnance disposal technicians. J Strength Cond Res XX(X): 000-000, 2020-Low fitness and poor functional movement (FM) have been linked to higher musculoskeletal injury risk. The FM Screen (FMS) and Y-Balance Test (YBT) are useful indicators of potential injury risk in military personnel. U.S. Navy Explosive Ordnance Disposal (EOD) technicians are the premier combat force for countering explosive hazards and must operate in austere environments. To safeguard health and mission success, it is critical to assess factors related to injury risk in this specialized military population. This study evaluated the relationship between fitness and FM characteristics in 64 male EOD technicians (mean age ± SD = 34.2 ± 7.0 years). Body fat percentage (BF%), maximum volume of oxygen uptake (V[Combining Dot Above]O2max), muscular strength, and FM (i.e., FMS, YBT) were assessed. Body fat percentage and V[Combining Dot Above]O2max were associated with FMS and YBT scores (all p < 0.05). A nonlinear model further revealed that the group with the lowest V[Combining Dot Above]O2max values had the bottommost FMS and YBT scores (all p < 0.01), but FM scores did not differ among those with a higher V[Combining Dot Above]O2max, implying a "threshold" effect. No correlations were observed with muscular strength. By characterizing the unique and shared contributions of BF% and V[Combining Dot Above]O2max, and exploring the nonlinear relationship between V[Combining Dot Above]O2max and FM, this study expands on accruing data that indicate individuals who are more physically fit have better FM and lower injury risk. Although muscular strength is a critical element of overall fitness, body composition and cardiorespiratory fitness may more strongly influence FM and injury risk.

Validity and Reliability of the New Basic Functional Assessment Protocol (BFA)

The global evaluation of motion patterns can examine the synchrony of neuromuscular control, range of motion, strength, resistance, balance and coordination needed to complete the movement. Visual assessments are commonly used to detect risk factors. However, it is essential to define standardized field-based tests that can evaluate with accuracy. The aims of the study were to design a protocol to evaluate fundamental motor patterns (FMP), and to analyze the validity and reliability of an instrument created to provide information about the quality of movement in FMP. Five tasks were selected: Overhead Squat (OHS); Hurdle Step (HS); Forward Step Down (FSD); Shoulder Mobility (SM); Active Stretching Leg Raise (ASLR). A list of variables was created for the evaluation of each task. Ten qualified judges assessed the validity of the instrument, while six external observers performed inter-intra reliability. The results show that the instrument is valid according to the experts' opinion; however, the reliability shows values below those established. Thus, the instrument was considered unreliable, so it is recommended to repeat the reliability process by performing more training sessions for the external observers. The present study creates the basic functional assessment (BFA), a new protocol which comprises five tasks and an instrument to evaluate FMP.

Exploring the Application of Pattern Recognition and Machine Learning for Identifying Movement Phenotypes During Deep Squat and Hurdle Step Movements

Background

Movement screens are increasingly used in sport and rehabilitation to evaluate movement competency. However, common screens are often evaluated using subjective visual detection of a priori prescribed discrete movement features (e.g., spine angle at maximum squat depth) and may not account for whole-body movement coordination, or associations between different discrete features.

Objective

To apply pattern recognition and machine learning techniques to identify whole-body movement pattern phenotypes during the performance of exemplar functional movement screening tasks; the deep squat and hurdle step. Additionally, we also aimed to compare how discrete kinematic measures, commonly used to score movement competency, differed between emergent groups identified via pattern recognition and machine learning.

Methods

Principal component analysis (PCA) was applied to 3-dimensional (3D) trajectory data from participant's deep squat (DS) and hurdle step performance, identifying emerging features that describe orthogonal modes of inter-trial variance in the data. A gaussian mixture model (GMM) was fit and used to cluster the principal component scores as an unsupervised machine learning approach to identify emergent movement phenotypes. Between group features were analyzed using a one-way ANOVA to determine if the objective classifications were significantly different from one another.

Results

Three clusters (i.e., phenotypes) emerged for the DS and right hurdle step (RHS) and 4 phenotypes emerged for the left hurdle step (LHS). Selected discrete points commonly used to score DS and hurdle step movements were different between emergent groups. In regard to the select discrete kinematic measures, 4 out of 5, 7 out of 7 and 4 out of 7, demonstrated a main effect (p < 0.05) between phenotypes for the DS, RHS, and LHS respectively.

Conclusion

Findings support that whole-body movement analysis, pattern recognition and machine learning techniques can objectively identify movement behavior phenotypes without the need to a priori prescribe movement features. However, we also highlight important considerations that can influence outcomes when using machine learning for this purpose.

Development and Reliability of an Athlete Introductory Movement Screen for Use in Emerging Junior Athletes

PURPOSE

A novel 4-task Athlete Introductory Movement Screen was developed and tested to provide an appropriate and reliable movement screening tool for youth sport practitioners.

METHODS

The overhead squat, lunge, push-up, and a prone brace with shoulder touches were selected based on previous assessments. A total of 28 mixed-sport junior athletes (18 boys and 10 girls; mean age = 15.7 [1.8] y) completed screening after viewing standardized demonstration videos. Athletes were filmed performing 8 repetitions of each task and assessed retrospectively by 2 independent raters using a 3-point scale. The primary rater reassessed the footage 3 weeks later. A subgroup (n = 11) repeated the screening 7 days later, and a further 8 athletes were reassessed 6 months later. Intraclass correlation coefficients (ICC), typical error (TE), coefficient of variation (CV%), and weighted kappa (k) were used in reliability analysis.

RESULTS

For the Athlete Introductory Movement Screen 4-task sum score, intrarater reliability was high (ICC = .97; CV = 2.8%), whereas interrater reliability was good (intraclass correlation coefficient = .88; CV = 5.6%). There was a range of agreement from fair to almost perfect (k = .31-.89) between raters across individual movements. A 7-day and 6-month test-retest held good reliability and acceptable CVs (≤ 10%) for sum scores.

CONCLUSION

The 4-task Athlete Introductory Movement Screen appears to be a reliable tool for profiling emerging athletes. Reliability was strongest within the same rater; it was lower, yet acceptable, between 2 raters. Scores can provide an overview of appropriate movement competencies, helping practitioners assess training interventions in the athlete development pathway.

Comprehensive movement system screening tool (MSST) for athletes: Development and measurement properties

OBJECTIVES

Non-traumatic extremity injuries are particularly common in sports, representing a significant economic, academic, and psychosocial burden on athletes. Proposed musculoskeletal risk factors for increased injury and decreased performance in athletes include movement pattern inefficiency, decreased regional stability, decreased mobility, and asymmetrical movement. The Movement System Screening Tool (MSST) is a comprehensive screening tool designed to assess these factors. Thus, the purpose of this study was to describe the development and determine the content and construct validity and inter-rater reliability of the MSST.

METHODS

A modified Delphi panel of experts determined content validity. 80 athletes (40 with and 40 without a current non-traumatic shoulder injury) completed 21 clinical tests, with exploratory factor analysis and known group analysis performed to determine construct validity. Two independent raters were used to establish individual item and composite score inter-rater reliability.

RESULTS

Exploratory factor analysis identified three of the four apriori constructs over 7 factors (14 tests), representing 63% of the variance. Known group analysis revealed a significantly lower composite score in athletes with vs. without a current non-traumatic shoulder injury (56.9±5.8 vs. 62.7±4.5, respectively). A preliminary cut score of 62 was chosen with sensitivity of 85% and specificity of 44%. Composite score inter-rater reliability was excellent ICC _(2,1)=0.94, 95% CI (0.91, 0.96) and item reliability ranged from κ=.57 to 1.00.

CONCLUSIONS

The MSST possesses constructs representative of injury risk and measurement properties acceptable for use in clinical settings. Comprehensive screens with construct validity and known measurement error are needed not only to identify athletes at risk of injury, but also provide an instrument that can be used in studies that seek to validate training approaches proposed to change movement impairment and injury risk in athletes.

A randomised controlled trial of movement quality-focused exercise versus traditional resistance exercise for improving movement quality and physical performance in trained adults

The aim of this trial was to compare an eight-week individual movement quality versus traditional resistance training intervention on movement quality and physical performance. Forty-six trained adults were randomised to a movement quality-focused training (MQ) or a traditional resistance training (TRAD) group, and performed two individualised training sessions per week, for 8 weeks. Session-RPE (sRPE) was obtained from each session. Measures of movement quality (MovementSCREEN and Functional Movement Screen (FMS)) and physical performance were performed pre- and post-intervention. All measures improved significantly in both groups (3-14.5%, p = <0.005). The between-group difference in MovementSCREEN composite score was not statistically significant (0.3, 95% CI -3.4, 4.1, p = 0.852). However, change in FMS composite was significantly greater in MQ (1.3, 95% CI 0.8, 1.8, p < 0.001). There were no significant between-group differences in physical performance (p = 0.060-0.960). The mean sRPE was significantly lower in MQ (5.25, SD 1.2) compared to TRAD (6.6 SD 1.0, p = <0.001). Thus, although movement quality scores were not distinctly greater in the MQ group, a movement quality specific intervention caused comparable improvements in physical performance compared to traditional resistance training but at lower perceived training intensity.

RELIABILITY of a MOVEMENT QUALITY ASSESSMENT TOOL to GUIDE EXERCISE PRESCRIPTION (MOVEMENTSCREEN)

BACKGROUND/PURPOSE

Movement quality is commonly assessed to identify movement limitations and guide exercise prescription. Rapid growth in the movement assessment landscape has led to the development and utilization of various movement quality assessments, many without reliability estimates. MovementSCREEN is a novel, tablet-based, video-recorded movement assessment tool, currently without published reliability information. Therefore, the purpose of this study was to determine the intra and inter-rater reliability of the MovementSCREEN, including the impact of rater experience, and provide estimates of measurement error and minimal detectable change.

STUDY DESIGN

Cross-sectional design; reliability study.

METHODS

Thirty healthy young adults (14M:16F, mean age 28.4 yrs, SD 9.1) were video recorded completing the nine MovementSCREEN assessment items on two occasions, two weeks apart. Each individual movement was assessed against objective scoring criteria (component items: yes/no) and using a 100-point sliding scale. To create an overall score for each movement, the scale score is weighted against the objective items to provide a score out of 100. At the completion of all nine individual movements, a mean composite score of movement quality is also established (0-100). The first recording was scored twice by two expert and two novice assessors to investigate inter- and intra-rater reliability. The second recording was scored by one expert assessor to investigate within-subject error. Inter- and intra-rater reliability was calculated using intraclass correlation coefficients (ICCs) and Kappa statistics. The standard error of measurement (SEM), and minimal detectable change (MDC95) for the overall score for each movement, and the composite score of movement quality, were calculated.

RESULTS

Intra-rater reliability for the component items ranged from κ = 0.619 - 1.000 (substantial to near perfect agreement) and 0.233 - 1.000 (slight to near perfect agreement) for expert and novice assessors, respectively. The ICCs for the overall movement quality scores for each individual movement ranged from 0.707 - 0.952 (fair to high) in expert and 0.502 - 0.958 (poor to high) in novice assessors. Inter-rater agreement for the component items between expert assessors ranged from κ = 0.242 - 1.000 (slight to almost perfect agreement), while for novice assessors ranged from 0.103 - 1.000 (less than chance to almost perfect agreement). ICCs for the overall scores for each individual movement from expert and novice assessors ranged from 0.294 - 0.851 (poor to good) and 0.249 - 0.775 (poor to fair), respectively. The SEM for the composite score was 2 points, while the MDC95 was 6 points, with an ICC 0.901.

CONCLUSIONS

The MovementSCREEN can assess movement quality with fair to high reliability on a test-retest basis when used by experienced assessors, although reliability scores decrease in novice assessors. Comparisons between assessors involve greater error. Therefore, the training of inexperienced assessors is recommended to improve reliability.

LEVEL OF EVIDENCE

2b.

Utility of FMS to understand injury incidence in sports: current perspectives

The Functional Movement Screen (FMS) is a popular movement screen used by rehabilitation, as well as strength and conditioning, professionals. The FMS, like other movement screens, identifies movement dysfunction in those at risk of, but not currently experiencing, signs or symptoms of a musculoskeletal injury. Seven movement patterns comprise the FMS, which was designed to screen fundamental movement requiring a balance between stability and mobility. The 7 movement patterns are summed to a composite FMS score. For an instrument to have wide applicability and acceptability, there must be high levels of reliability, validity, and accuracy. The FMS is certainly a reliable tool, and can be consistently scored within and between raters. Although the FMS has high face and content validity, the criterion validity (discriminant and convergent) is low. Additionally, the FMS does not appear to be studying a single construct, challenging the use of the summed composite FMS score. The accuracy of the FMS in screening for injury is also suspect, with low sensitivity in almost all studies, although specificity is higher. Finally, within the FMS literature, the concepts of prediction and association are conflated, combined with flawed cohort studies, leading to questions about the efficacy of the FMS to screen for injury. Future research on the use of the FMS, either the composite score or the individual movement patterns, to screen for injury or injury risk in adequately powered, well-designed studies are required to determine if the FMS is appropriate for use as a movement screen.