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Stanford Cook-McGill Review

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ASSESSING MOVEMENT: A CONTRAST IN APPROACHES & FUTURE DIRECTIONS 

co-hosted by Stanford Sports Medicine and Rehab2Performance

Craig Liebenson, DC, Stuart McGill PhD, and Gray Cook, PT
What a trio. (left to right)
Craig Liebenson, DC, Stuart McGill PhD, and Gray Cook, PT

Two giants in the field, Gray Cook, PT and Stuart McGill, PhD, assembled to present their viewpoints on movement assessment, arranged and moderated by Craig Liebenson, DC.  Assessing Movement: A contrast in approaches & future directions was held at Stanford University and co-hosted by Stanford Sports Medicine and Rehab2Performance.  Such a prestigious location was fitting, and even led to Gray uncharacteristically appearing in a jacket (which didn’t last the whole day, and he quietly told me “jackets are for funerals and Stanford”).  For the nearly 350 professionals in attendance, it was nothing short of spectacular.  With representatives from Asia, Europe, and throughout North America ranging from students, to fitness professionals, performance coaches, and clinicians, there was a bit of perspective for everyone. (For those who didn’t attend, the event was recorded and a DVD copy can be obtained here; use coupon code StanfordCL.)

The community created by such an event fit perfectly with the principles and mission of Rehab2Performance (R2P) which is an unaffiliated network of professionals striving to combine the best from various teachings.  R2P is about creating the perfect blend of approaches, creating a network of exceptional professionals, and providing services along a continuum of care.  This meeting exemplified R2P's mission.  (and for those professionals who share that mission, we welcome you to join the R2P network.)

What should not be lost in anything else you read is that this was a top-notch event and a discussion that should continue.  The level of transparency, mutual respect, and openness to change in light of new evidence that the presenters displayed should be emulated.   I entered this meeting holding the presenters in the highest regard; I left after solidifying my appreciation for their work and with a deeper awareness of their character.

Dr. McGill presenting his thoughts and Gray Cook, PT enjoying the commentary.
Dr. McGill presenting his thoughts and
Gray Cook, PT enjoying the commentary.
This truly was an enjoyable, collegial discussion.

Dr. McGill presenting his thoughts and Gray Cook, PT enjoying the commentary. This truly was an enjoyable, collegial discussion.

While some anticipated a heated battle, what we got was a level-headed, respectful discussion of some age-old conflicts, with a contemporary twist including the FMS and current research.  Gray Cook, PT stated, "I'm not offended by scientific scrutiny"...."I'm honored".  Dr. McGill, on many occasions, said "I cannot disagree with anything I've heard".  Throughout this fantastic day Cook and McGill offered pearls of wisdom, as Liebenson masterfully guided the conversation and the audience's questions.  The discussion included many perspectives and dichotomies we all wrestle with.

Theory vs. Practice or (Concept vs. Concrete data)

'In theory, theory and practice are the same. In practice, they are not.' – Albert Einstein

Gray spoke primarily of the theory of why we need movement assessment, the failures of the structural and pain-centric models and the concepts the FMS is based upon.  He deftly painted a vision of a future with a benchmark assessment for movement, analogous to taking a blood pressure.  McGill agrees with failures of the structural model but points out some limitations to the FMS including the uniqueness of individual anatomy (discussed below), the choice of what is measured with the screen, and questions whether or not the FMS is the benchmark test we need it to be.  Whether you agree or disagree with each point, I think we can acknowledge that we all wrestle with trying to find the best way to turn a great concept into a practical application.  I don’t see many (including McGill) lining up to challenge the concepts Gray presents, but I think there is room to further evaluate the application. [For those not already intimately familiar with the wonders of the FMS, go take the course.]

In his introduction Gray acknowledges that the FMS is static, unloaded, of controlled velocity, and that it isn’t a test for injury risk.  This preempted and prepared the audience for several of the arguments McGill intended to make.  Gray’s understanding of the limitations of the FMS should be lauded.  We are all best served to know our strengths and limitations.  However, it does not make some of the criticisms not worth considering.  While the FMS acknowledges it does not include certain aspects, this does not prevent the rest of us from asking the philosophical question, “should it?”  Despite the issues to be raised below, the FMS is the premier movement screen for the pain free individual.   As we ask these questions let's not forget that and let's be sure we don't accidentally throw the baby out with the bath water.

Speed or Load

McGill challenges that an unloaded test doesn’t predict what happens when load or speed are added.  He presents evidence that movement changes in both directions (improvement and degradation).  This begs the question; does this lend the FMS to be a valid predictive model?  A screen that determines competency to attempt speed or load?  While the red light of pain during FMS is a clear indication to STOP, are the green light and yellow light as clear as they need to be?

Biomechanical injury mechanisms  

Gray acknowledges that injury mechanisms were left off the FMS.  He stated that this was done on purpose, as the goal of the FMS is to create a movement baseline.  Does this create the most robust screen?

Stu notes that common injury mechanisms including lumbosacral flexion and valgus collapse of the knee are not directly assessed.  Finding biomechanical injury predictors is not easy. As these 2 are clearly identified through McGill’s spine research and the ACL research of Hewett and Powers, is it wise to ignore them? Or perhaps more fairly tangentially assess them?

Side note: during the demonstration an audience member (Will Nassif) was used to demonstrate the FMS.  He scored all 2s and a 3 (squat) for a symmetric 15.  McGill then used this same fit individual to demonstrate a rope pulling assessment.  After a few efforts, McGill disqualified the person, not for capacity shortfalls, but for a lumbar spine position and presentation that indicates a splinted disc (unresolved prior injury).  He stated ethically he could not ask the person to continue for the point of the demo.  In Dr. McGill's opinion the subject was not qualified to perform the task and capacity could not be assessed.  Does this demonstrate a shortcoming of the FMS?  Or does it simply illustrate the need for further assessment after a movement screen to fully establish competency?  The question for all of us is, at what point can we confidently begin capacity testing?

Endurance  

The FMS is a maximum 3-repetition screen as demonstrated by Kyle Kiesel, PT, PhD during demonstration.  As such, endurance does not become a factor in the scoring.  Professor McGill points out that as fatigue or lack of endurance is a factor in occupational injuries and it is known impact movement quality as well. Perhaps this is a valuable quality to assess?  Sorenson’s back endurance test and a variety of measures of aerobic fitness come to mind.  Cook points out that this is not the intent of the FMS and would increase the time needed to perform the screen.  For those who train individuals, you are most likely already using a second assessment to identify capacity/fitness shortfalls.

Transfer (Ability vs. Habit) 

McGill continues that the FMS tests ability not habit, and the latter is most important in assessing injuries.  Just because someone can does not mean they will.  Does the FMS score predict the movement behavior in life or sport?  McGill also questioned that if the FMS is not generalizable to other activities, is it valid to make decisions based upon its results?  Cook noted that prior to validity, reliability must be established, which it has been (more discussion below).

Screen vs. Assessment

(Efficient vs. detailed; How much do you need? When is it enough?  Can it be too much? When do we cross the threshold into paralysis by analysis?)

The screen must be simple enough to be reliable.  Cook relates that the screen is simple for a reason; adding further tests, creating complexity, and adding judgment calls will cause reliability to plummet.  If reliability suffers, validity will be out the window.

McGill began his portion of the program noting that this was an age-old question, one that he tackled on his first research venture 30 years ago.  How simple does something need to be in order to be accurate and reproducible?   How complex does it need to be to have meaning and significance? To use a phrase you’ll hear often on the DVD, I guess, “it depends”.

Ease of administration and teaching vs. complex with a need to master

Cook’s vision of the screen being a blood pressure test for movement requires that it is easily and widely administered. Effective application means it must be something that could be taught to gym teachers, YMCA employees, and youth coaches.  These well-intentioned, but often less-trained individuals need to have reliable results.  Contrast this with a clinical assessment by a highly-trained and experienced practitioner.  McGill points out that his approach (the latter), is very difficult to teach, highly detail oriented, and individualized during each assessment.  Stu relates that he sees patients for a 3 hour initial assessment, but we must remember these are back pain cases that have failed more than a handful of interventions or elite athletes in search of a unique solution.  Comparing highly skilled clinical exams and general population movement screens is not exactly an apples to apples comparison.  McGill suggests that the FMS is a great introduction to assessment for more novice coaches and clinicians.  Is the FMS the starting point?  Not only for athletes and non-injured adults, but perhaps for training those new to movement assessment?

Standard Operating Procedure vs. Individualization

Are we all more similar or more different?  Yes.

The argument made by the Checklist Manifesto and Blunder, which Gray referenced during his talk, is that even highly trained individuals can overlook items and therefore will achieve the best results by reducing human error through a checklist or standard operating procedure.  The evidence from airlines to surgery makes this a compelling argument for the SOP approach.  The other consideration is that the human species share some unique characteristics that we could use as benchmarks: upright posture, bipedal gait, respiration stereotype, squat pattern, etc.   However, on the other hand, McGill argues for individualized assessment.  He points to unique anatomy based on genetics and references hip joint architecture and disc morphology as prime examples.  Beyond anatomic variation, we must also acknowledge injury or surgical history, past training experience/current fitness level, as well as emotional/psychological factors.  Can you truly make each person’s assessment the same?  It seems that even the way we talk to someone must be individualized when performing the same test.  Should an assessment be uniform (S.O.P) or should it be individualized?  Yes.  In my opinion a blended approach is needed.  To what degree they are standardized and to what degree they are individualized is up to your expertise.

Communication

One topic that wasn’t discussed in detail, but was touched upon by Cook was improved communication.  Above all else, it is my opinion that the lasting contribution of the FMS will be its movement scoring and its contribution to communication channels.  The ability to bucket movements into 0s, 1s, 2s, and 3s not only facilitates understanding, it guides decision-making, and most importantly improves communication along the continuum of care.  Getting coaches, trainers, and health care providers to speak in similar terms is no small accomplishment.  Athletes and patients alike will benefit from our improved avenues of communication.

 

In review, we have 2 exceptionally gifted gentlemen who couldn’t have been more complimentary of one another.  They acknowledge that their opinions differ in some areas and both articulated their viewpoint with the most professional of ethics.  The path going forward was covered by Craig Liebenson in his wrap up which you’ll see on the DVD.  However, despite the reflection and direction Liebenson shared, the future is truly up to you.

To be critical, the one place I wish there was improvement was in the Q&A.  While the presenters began the day on fire, we the audience sputtered and took some time to warm up.  The questions improved as the day went on.  However, the energy levels left in our presenters understandably waned at the end.  If we could have better paired the quality questions with the right time to ask them, even more would have been gained from this discussion.

Early in the day, McGill offered that he would try to take the road of an expert witness, presenting information but leaving the audience to make up their own mind.  Cook took a compatible approach noting that we need a movement screen, and made the analogy that he may have created the compass and the future may deliver a GPS.  Cook’s caution was, "don’t throw out your compass until you have a GPS".  I give Gray a lot of credit for his openness, as he stated that if he someday finds a system that he believes is superior to the FMS, he will gladly adopt it.  I hope this overview has achieved some degree of the openness the presenters desired and has left you room to apply your thoughts, knowledge, and critical thinking skills.

Credit is due to both of these gentlemen for their efforts and dedication to advancing our knowledge and practice.  We have leapt forward on the shoulders of these giants.  As we more deeply understand their works, we will develop better questions, upgraded hypothesis, and eventually solutions will emerge.  I am confident that the next leap forward will be from someone who thoroughly digested the contributions of these great men.

Also a huge thank you to Dr. Craig Liebenson for assembling such an event and to Laree Draper who will immortalize it and provide it to all those who regret their lack of attendance.

- Jason Brown, DC

Discounted DVD of the event.  Click here & use coupon code StanfordCL.

Other reviews of the event:

Phil Snell, DC @myrehabexercise.com - Stanford 
Patrick Ward, MS, CSCS, LMT @optimumsportsperformance.com
Bobby Maybee, DC Facebook review reposted
Dan John ("Back" from Stanford)
Dave Draper

Other resources:
FMS course list
McGill's courses
Liebenson's courses
R2P CERT