Athletic performance in professional sport is widely followed and highly researched. The majority of research in this area has been focused on optimizing the physical and physiological performance capacities of competitive athletes while minimizing adverse events that may lead to missed training and performance/playing time. The Functional Movement Screen (FMS) was developed as a whole-body assessment of fundamental movement patterns that encompass the basis for athletic movements and sport performance (4,5). The FMS was the result of a paradigm shift among movement specialists, therapists, qualified exercise professionals, and strength and conditioning professionals toward a more “functional” approach to identifying deficiencies that could prevent injuries associated with improper exercise execution, physical asymmetries, injury rehabilitation, and physical fitness training (4,5).
The FMS consists of 7 different movements that are each scored on a scale of 0–3, and 2 of these movements also include specific pain clearance tests. The FMS protocols were developed to collectively provide a tool to assess dynamic movement using the concepts of kinetic chain systems and proprioception (4,5). The FMS is ideally suited to be incorporated into a comprehensive medical and/or physical fitness evaluation for both recreational and high-performance athletes. Functional Movement Screen outcomes can be used to identify deficiencies in fundamental movement patterns and to detect left-right asymmetries that occur during these movements (4,12,16). Although the primary goal of the FMS is the assessment of movement patterns and identification of deficiencies that may increase injury risk, the FMS has also been used as a tool to evaluate the efficacy of exercise training programs, although research is limited in this area (11,17).
Regardless of its intended application, the FMS has been shown to demonstrate high levels of interrater and intrarater reliability when conducted by individuals with adequate training using both real-time scoring and video-based analysis (10,19). The majority of research pertaining to the FMS and its applicability has been conducted on healthy recreational athletes, professional football players, military recruits, and workers in physically demanding occupations (firefighting) (6,8,9,11,16,18). To date, there have been no published studies involving the use of the FMS with elite hockey players. The most recent survey conducted with NHL strength and conditioning coaches was undertaken in 2004, and at that time, only 1 respondent was using a system analogous to the FMS (7), and it is unclear how this FMS information was being used. Further investigation is certainly warranted to evaluate the utility of the FMS for future and present NHL players with respect to injury risk prevention, strength and conditioning practices, and performance optimization.
The annual NHL Combine is a multiday event that hosts the top 100 junior age prospects from around the world. The players undergo comprehensive medical evaluations that include medical history, physical examination, orthopedic examination, electrocardiogram, echocardiogram, and motor coordination together with a battery of physical and physiological fitness tests that assess muscular strength, muscular endurance, muscular power, anthropometry, body composition, agility, anaerobic, and aerobic power. To date, the published research on this cohort has focussed on the outcomes of the NHL Combine assessments as they relate to a player's hockey potential and draft status (1,2,21). Before 2013, there has been no assessment of basic functional movement patterns in the test battery conducted at the NHL Combine, but a growing interest among NHL strength and conditioning coaches led to the inclusion of the FMS in the test battery at the 2013 NHL Combine.
From a practical standpoint, the content of this investigation is of great interest to strength and conditioning specialists both at the professional and amateur level. Detection of potential imbalances or deficiencies in functional movement patterns may help tailor individualized training programs for ice hockey players with the goal of injury risk reduction/prevention and enhanced hockey performance. Within the scope of the NHL Combine assessments, it was hypothesized that there would be a number of interesting correlations that link the outcomes of the FMS to other medical, physical, and physiological measures that will provide valuable insight to scouts, strength and conditioning specialists, and sports medicine practitioners. The 2 primary objectives of this investigation were to describe the outcomes from the NHL Combine FMS assessments and to determine whether they correlate with results from the associated medical, physical, and physiological assessments. A third objective was to create strategies, based on expert opinion, that may enhance the efficacy of FMS testing at future NHL Combines and for use among strength and conditioning professionals in other sport settings.
Experimental Approach to the Problem
This study evaluated the outcomes of integrating the FMS into the NHL Combine and identified any links to other medical and fitness assessment outcomes using a nonrandomized cross-sectional design. The top 111 elite junior hockey players from around the world took part in the 2013 NHL Combine. The medical, physical, and physiological status of the players was evaluated through a series of comprehensive assessments pertinent to hockey performance. Of particular interest to strength and conditioning specialists is the recent integration of the FMS into the NHL Combine test battery. The comprehensive medical, physical, and physiological assessment customarily performed at the NHL Combine allows for comparison with the FMS outcomes, with the goal of establishing relationships to injury risk and limitations to performance that may assist various health and qualified exercise practitioners when developing training programs.
In 2013, the top-ranked 101 junior hockey prospects from around the world with a mean age of 17.8 (SD ± 0.4; 17–19 years old) years took part in the NHL Combine. The study population included players at each position: forward (n = 59), defense (n = 34), and goaltender (n = 8). Players with current musculoskeletal injuries that precluded them from performing the FMS in its entirety were excluded from this data analysis. All players provided signed informed consent before their involvement in the NHL Combine. If the player was younger than 18 years, parental or guardian consent was obtained. Permission to report these data in aggregate form was received from the players involved and from the NHL. The methods used in this investigation have been approved by the York University Human Participants Review Subcommittee.
Functional Movement Screen
The FMS was performed 1–3 days before all other medical, physical, and physiological fitness assessments. This range in the timing of FMS testing was due to scheduling limitations, arrivals of international players, and the fact that the remainder of the medical/fitness testing was held over a 2-day period. Despite these scheduling constraints, the FMS assessments were all performed during the evening over the specified 2-day period. It should also be noted that the participants were not instructed to adhere to any particular nutritional guidelines. The testing venue consisted of 4 stations, with the testing at each station conducted by the same qualified examiners for all athletes. The players performed each of the 7 FMS movements in a randomly assigned order. Station 1 was the deep squat. Station 2 included both the hurdle step and the in-line lunge. Station 3 included both the shoulder mobility and active leg raise along with the active impingement pain clearance. Station 4 included both the trunk stability push-up and the rotary stability tasks along with the pain clearance for both lumbar extension and flexion. The randomly assigned order and the use of 4 stations allowed multiple players to be assessed simultaneously.
Scoring adhered to the FMS guidelines and all testers who conducted the scoring underwent approximately 20 hours of specific training using FMS-endorsed teaching materials (video and manual) before the testing. All participants were provided with identical verbal instructions and photographs of the start and end positions for each movement. In addition, because of language limitations among this diverse population, a demonstration of proper technique was provided for each task. The demonstration was provided by the same testers for each of the 7 tasks. Three attempts for each test were provided to the players in the event that a score of 3 was not attained on the initial or second trial. A customized scoring sheet was developed to gather additional information regarding why a score of 3 was not achieved and to further document any asymmetries between the left and right side of the body. These documented infractions are based on the descriptions of the FMS protocols and scoring system, and they include limited range of motion, loss of balance, and several task-specific items, which are all outlined clearly in Figure 1. The selection of a “slight” vs. a “significant” infraction was subjectively determined by the testers at each station. For the purpose of the data analysis, slight and significant infractions were subsequently merged into a single category of “infractions” because of the potential limitations associated with subjective scoring. Each task was individually scored out of 3, and a total score out of 21 was recorded for each participant together with the total number of asymmetries identified and the pain clearance results. Asymmetries were noted when a participant attained a different score on one side of the body compared with the other. Asymmetries could not be added to the score sheet for the deep squat and the trunk stability push-up because neither movement is performed unilaterally.
All players underwent medical history, and physical examination and orthopedic examination were performed by the same 3 physicians before undergoing any further testing. These physician assessments were followed by an electrocardiogram (Mortara ELI 100, Milwaukee, WI, USA) and an echocardiogram (Philips iE33 xMatrix, Andover, MA, USA), which were all evaluated by the same cardiologist for the detection of potential arrhythmias or cardiomyopathies. During the medical evaluation, the following information was recorded: level of body development, assessment of neuromuscular function and joint range of motion, current and previous injury (including treatments and/or surgeries), and current use of medications/supplements. Information was also gathered about the number of years playing hockey, days since last game, days since last off-ice workout, plus the type and intensity of exercise training routinely performed.
Physical and Physiological Fitness Evaluations
The physical and physiological fitness evaluation encompassed 4 primary components. The first component was anthropometry and body composition: height, body mass, wing span, standing reach height, and percent body fat from skinfold calipers (West Sussex, United Kingdom) using the Yuhasz sum of 6 skinfolds formula (3). The second component was the assessment of selected musculoskeletal components: a hand grip dynamometer (Takei T.K.K. 5401, Niigata, Japan), the Gledhill Force Meter for upper-body push and pull strength, maximum number of push-ups performed to a metronome (50 b·min−1), maximum number of 150 lb bench press repetitions to a metronome (50 b·min−1), upper-body power using a 2-handed seated 4 kg medical ball put, standing long jump and lower-body power using both vertical jump (both squat jump and countermovement jump (2)) on the Vertec (JumpUSA, Sunnyvale, CA, USA), and a 4-jump protocol using the Probotics “Just Jump” vertical jump mat (Probotics, Inc., Huntsville, AL, USA). The third component was the assessment of anaerobic power and %fatigue index using a 30-second Wingate cycle ergometer (Monark 894E, Vansbro, Sweden) protocol against a resistance equal to 0.09% of the player's body mass. The fourth and final component was the direct assessment of aerobic power on a cycle ergometer (Monark 874E) for the determination of maximal oxygen consumption (
) using a customized loading sequence and direct gas analysis with expired air collected by a Tissot gasometer. The attainment of
was confirmed when the
value leveled off with increasing work rates or when the athlete was no longer able to consistently maintain a pedaling rate greater than 70 rpm. The athletes were allowed a minimum of 30-minute rest between the Wingate and
The players' medical, physical, and physiological fitness data were summarized using descriptive statistics (mean ± SD) and frequencies (n, %). Pearson's correlations were performed to test the hypothesis that FMS outcomes would be linked to components of the other health, physical, and physiological outcomes assessed during the NHL Combine. The analysis was performed on FMS total scores and the number of left-right asymmetries and total number of documented FMS infractions compared with various quantifiable components of the medical, physical, and physiological fitness evaluations. It should be noted that the use of “documented FMS infractions” in the analysis has not been performed previously in the literature. The accepted alpha level of significance was set a priori at p ≤ 0.05 for all correlations. All analyses were performed using IBM SPSS Version 20 (IBM Corp., Armonk, NY, USA).
Of the 101 players who attended the NHL Combine, 88 completed the FMS testing. The 13 players who did not participate in the FMS had acute musculoskeletal injuries that precluded their involvement. Complete physical and physiological fitness data were obtained for 81 of the NHL Combine participants. Twenty of the players did not perform select components of the physical and physiological fitness assessment because of current musculoskeletal injuries identified during the medical evaluation. Figure 2 summarizes the involvement of the athletes. Player demographic and anthropometric data are presented in Table 1.
Functional Movement Screen
Table 2 provides a summary of FMS results. The mean FMS total score out of 21 from all players was 15.2 ± 2.51, and the mean number of left-right asymmetries identified was 0.9 ± 0.91. The FMS movement for which the athletes most frequently received the highest score of 3 was the trunk stability push-up (68.2%), whereas the movement that was performed most poorly was the rotary stability task, with 98% of athletes receiving a “2” or lower.
Results from the medical evaluation are summarized in Table 3. Based on the physicians' evaluation of the players' overall health status, 62.6% of the players were identified as being “healthy,” 16.5% were “healthy with a slight injury,” and 20.9% were deemed “not healthy,” primarily due to an acute injury. The latter percentage corresponds to the percentage of the athletes (21.1%) who self-reported having some form of unhealed injury. Table 3 also shows the mean elapsed time since the players' last game and information regarding their regular training regimen. Furthermore, there were no cardiomyopathies or arrhythmias identified during the medical evaluation.
Physical and Physiological Fitness Evaluations
The physical and physiological data of the athletes are summarized in Tables 1 and 4. Upper- and lower-body musculoskeletal fitness measures, Wingate test, and
results are presented in Table 4.
Correlation of the Functional Movement Screen to Medical, Physical, and Physiological Fitness Data
The total FMS score and the medical evaluation were significantly correlated with several outcomes from the medical, physical, and physiological fitness assessments. The statistically significant (p ≤ 0.05) correlations between the FMS score, the number of asymmetries identified by the FMS, and the number of infractions to the measures collected during the NHL Combine are summarized in Table 5.
The 2 primary objectives of this investigation were to describe the outcomes from the NHL Combine FMS assessments and to determine whether they correlate with the results from the associated medical, physical, and physiological assessments. The third objective was to create strategies, based on expert opinion, that may enhance the efficacy of FMS testing at future NHL Combines and for use among strength and conditioning professionals in other sport settings. The FMS mean total score of 15.2 is lower than that reported for a different professional athlete population (football players) (12), but there have been no other published studies involving the administration of the FMS to recreational or elite hockey players and therefore it is difficult to determine if the sport of hockey may be predisposing players to lower scores on the FMS based on the sport-specific movement patterns that have been used and developed during player development. The number of asymmetries identified (mean = 0.93) appears to be quite low, but there is no relevant population described in the literature with which a comparison can be made. The movements performed with the highest (trunk stability push-up) and lowest (rotary stability task) success rates are in line with those observed in other studies (16,18), which may simply be a reflection of the difficulty or complexity of the movements themselves, as opposed to a result of sport-specific functional movement pattern alterations. The scoring system used in this study was unique in that a quantifiable system of FMS performance infractions was implemented with a mean of 24 infractions noted. Although not previously used or reported in the literature, this system of tracking infractions may be useful to inform the design of functional exercise training prescriptions by strength and conditioning coaches and warrants further investigation. Tracking additional infractions will allow strength and conditioning professionals to further detect individual differences in an apparently homogeneous population of athletes based on FMS total score alone. These individualized programs may be more successful in correcting or minimizing the deficiencies identified by the FMS by adopting training techniques that focus on improving the specific infractions, which contributed to lower overall FMS scores. The goal of such programs should be to ultimately reduce injury risk and potentially improve hockey performance.
The investigation into correlating the FMS results with the medical, physical, and physiological fitness evaluations results only revealed a small number of relationships. The total FMS score, number of asymmetries identified, and total number of infractions identified on the FMS exhibited statistically significant correlations that were seemingly slight, coincidental, or even counterintuitive in their directionality when linked with the outcomes from the medical, physical, and physiological fitness test results. This may simply be a result of the homogeneity of the participant population or due to a lack of concordance between FMS scores and performance outcomes, which is consistent with the existing literature on the subject (15,17). For example, the link between peak leg power and FMS total score (Pearson Correlation Coefficient [PCC] = −0.242) implies that with increases in FMS total score, there is a corresponding low peak leg power. Of particular note was the correlation between the FMS total score and days since last off-ice workout (PCC = −0.245). This correlation, although it is not particularly strong, makes sense from the perspective that those who were participating in regular conditioning programs in the days immediately preceding the Combine would perform better on the FMS.
Unfortunately, what the authors did not determine, and what would be very informative, is the number of athletes who are currently under the regular supervision of a strength and conditioning coach, the number of athletes who have undergone the FMS before the Combine, and the number of athletes who incorporate “functional movement corrective training” into their regular conditioning regimes. Although previous studies have demonstrated good test-retest reliability (14,20) when using the FMS, there is potential for learning effects associated with familiarization with the test itself. Furthermore, if there were athletes who had previously completed the FMS, the allowance of 3 attempts would mitigate any potential advantages that those with experience may possess. Also, studies have shown that, with corrective exercises and focused training, athletes can improve their FMS scores (11). Information about previous FMS experience would be valuable for scouts and strength and conditioning professionals with regard to the amount of weighting they place on the FMS scores established during the NHL Combine. These questions should be incorporated into future medical evaluations at the NHL Combine so that more detailed information regarding training habits can be examined and if there are correlations between previous experience performing the FMS and the FMS score at the NHL Combine. The apparent lack of concordance between the FMS and results from the medical evaluation is of particular interest and warrants further investigation regarding any potential links between long-term injury outcomes and FMS performance.
Potential limitations of this investigation include the use of tester demonstrations for each of the FMS movements. This has not been performed in previous studies, and little is known about how the inclusion of a demonstration may alter the FMS scores. The rationale for this inclusion was (in addition to language barriers) an attempt to evaluate players based on their ability to fully perform the movements as they were designed rather than how they interpret instructions and choose to execute the movement. However, the authors believe that the inclusion of tester demonstrations is an improvement in the FMS protocol. Another potential limitation was the randomized order used for the FMS movement evaluations. Although it has been implied that the FMS movements should be evaluated in the same specific order that they are outlined in the original FMS publications (4,5), 1 recent study has demonstrated good reliability when randomly assigning the order of the movements (20). The choice for randomized movement order was made to optimize the use of time during the NHL Combine and 4 stations were setup with the same testers scoring each task for all athletes, thus allowing 4 athletes to be tested within the same scheduled time frame.
In the future, the NHL Combine should ideally include video analysis for all athletes performing the FMS, which would allow for the assessment of interrater and intrarater reliability for FMS scores and the use of “documented infractions” as an auxiliary measurement within this sport-specific population. The videos would also provide the baseline assessment that may be used by the strength and conditioning professionals with the team that the player is drafted by during subsequent pre-season, mid-season, or off-season training. Furthermore, these videos with accompanying scores can be integrated into an NHL database that will be bolstered with new participants annually so that it will be possible to compare a larger pool of hockey players to potentially reveal stronger or more meaningful relationships to the medical, physical, and physiological fitness results. It should be noted that the NHL has committed to using video analysis for all athletes during the 2014 Combine, allowing for subsequent investigation into the scoring system, the long-term monitoring of athletes, and its utility among strength and conditioning professionals. Considering the apparent lack of correlation between FMS scores and performance-related physical and physiological outcomes at the NHL Combine, the main focus for the utility of the FMS should be on injury risk and prevention through proper strength and conditioning programming. To improve the efficacy of the continued inclusion of the FMS at future NHL Combines, the investigators highly recommend the implementation of a year-round injury surveillance system that would allow follow-up assessment and comparison with FMS scores measured during the NHL Combine. This would enable an evaluation of the value of FMS scores to assess injury risk among elite hockey players through retrospective analyses of the FMS data collected during the NHL Combine along with data from our proposed injury surveillance system. With regard to injury prediction, previous literature has shown that FMS scores below 14 have been significantly associated with increased injury risk both among elite football players and military recruits (11,13,16). The observation that injury risk was associated with FMS outcomes in elite football players is interesting in that both football and hockey are high impact sports with a very high risk for injury. Any information that may help identify those players at risk so that corrections can be made to potentially dysfunctional movement patterns, by strength and conditioning regimen, should be considered important. Among the present group of athletes, 18.2% scored 13 or lower, which may mean that given the evidence provided above, they are at risk for future injury.
Despite the increasing use of the FMS by qualified exercise professionals, coaches, and strength and conditioning specialists who work with both recreational and elite athletes for evaluating deficiencies in functional movement patterns, identifying injury risk and informing strength and conditioning regimens, very little is known about its effectiveness as it relates to the sport of ice hockey. Although this study observed some correlations between select components of the medical, physical, and physiological fitness data and the results of the FMS, further investigation into these relationships is necessary and is encouraged. Enhanced understanding of practical implications for the FMS outcomes, as it pertains to ice hockey, may translate into significant improvements in athletes' functional movement patterns, injury prevention, plus strength and conditioning strategies focused on correcting the individual infractions detected by the FMS that could lead to consistent and enhanced sport performance. In addition to examining the current strength and conditioning regimen and use of the FMS among NHL prospects before the Combine, the adoption of more comprehensive evaluation protocols that include the use of video analysis for FMS components and the implementation of a year-round injury surveillance program for future and present NHL players are highly recommended. This will permit further examination into the relationship between FMS outcomes (total score and documented infractions) and injury risk and for the development and evaluation of injury prevention programs that are implemented as a result of the findings from the surveillance system. Ultimately, any tool, such as the FMS, that could potentially benefit the health, assessment, training, or performance of elite athletes should be thoroughly explored so that its application can be maximized.
The authors would like to acknowledge Mr. Dan Marr and the National Hockey League Department of Central Scouting for the use of the data from the Combine. The authors would also like to acknowledge Dr. Scott Gledhill, Dr. Robert Brock, Dr. Peter Rowan, Dr. Chi-Ming Chow, and Dr. Quan Chan for their involvement in the medical evaluation process. The authors have no conflicts of interest to disclose, and this work was funded through internal York University research funding. The results from this study do not constitute endorsement of any products mentioned by the authors or the National Strength and Conditioning Association.
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Keywords:Copyright © 2015 by the National Strength & Conditioning Association.
FMS; hockey performance; injury prevention; sports medicine; fitness assessment