Most trainers, massage therapists, and strength coaches do not possess an adequate skill-set when it comes to screening and assessment. This isn’t necessarily their fault as it is poorly taught in most of these profession’s educational curriculum. In fact, so many people get very nervous and almost paralyzed by the idea of having to do some screening or evaluation that they choose to do nothing instead. Some people get so carried away with ridiculous assessments that are practically meaningless that it’s easy to see how one could get a nasty case of “paralysis by analysis!”
However, having a basic evaluation system for things like full-body mobility and movement capacity (including stability) will really set you apart from other professionals and allow you to be more effective at your job. The key is to stay within your specific scope of practice and realize that as non-medical professionals, we cannot “diagnose” anything and are simply obtaining information on each client to guide their safety and effectiveness in movement/exercise. It is especially helpful to know when to refer out when you arrive at red flags. Red flags are things like pain or strange or unexplained symptoms that would be better carried out by licensed medical professionals that are trained to look and treat these types of things. Here is short list of potential red flags to watch out for:
Red flags for spine fracture
Deep Back/Spine Ache that doesn’t fit usual back ache
Major trauma such as vehicle accident or fall from a height
Minor trauma, or even just strenuous lifting, in people with osteoporosis
Red flags for cancer or infection
Flags from medical history
Age over 50 years and new back pain, or age under 20 years
History of cancer
Constitutional symptoms, e.g. fever, chills, unexplained weight loss
Recent bacterial infection (e.g. urinary tract infection)
Intravenous drug abuse
Pain that worsens when supine; severe night-time pain; thoracic pain
Flags from physical examination
Red flags for cauda equina syndrome or rapidly progressing neurological deficit
Flags from medical history
Recent onset of bladder dysfunction (e.g. urine retention, increased frequency, overflow incontinence)
Recent onset of fecal incontinence
Flags from physical examination
Severe or progressive neurological deficit in the lower extremities
Unexpected laxity of the anal sphincter
Perianal/perineal sensory loss
Major motor weakness: knee extension, ankle plantar eversion, foot dorsiflexion
In this blog Keats Snideman is going to take Bret Contreras through a basic length-tension (mobility/flexibility appraisal) screening system that he uses to evaluate his clients. This screen is used in addition to more dynamic movement screening that includes the FMS (Functional Movement Screen) as well as some basic table assessments. This blog will show videos outlining his table assessments.
The Functional Movement Screen (FMS)
Before we move onto the table assessments, it is important to have a basic understanding of the FMS. The FMS is a 7 test screen developed by Gray Cook and Lee Burton used to evaluate fundamental movement patterns. The screen will assess risk and can identify situations where the client experiences pain and should be referred to a specialist, situations where a client needs to work on balancing out asymmetries, situations where a client needs to work on increasing mobility, stability, or motor control to improve a particular pattern prior to engaging in various activities. The 7 tests include the deep squat, hurdle step, inline lunge, shoulder mobility, active straight leg raise, trunk stability push up, and rotational stability. The FMS is a very valuable assessment tool that every trainer should incorporate into their arsenal.
Basic Table Assessments
The table assessments that Keats uses consists of a breathing pattern assessment, a head & neck mobility assessment, a t-spine mobility assessment, a shoulder mobility assessment, and a hip, foot & ankle, and big toe mobility assessment. These basic tests are assessing what is called ”passive movement testing” (although they can all be done actively as well). Passive movement can be further broken down into what is called “physiologic motion,” which is what we are going to be demonstrating, and “accessory joint motion” (joint play, component movements). Accessory movement testing is beyond the scope of testing for the intended audience of this blog so those tests should be left to licensed professionals trained in orthopedic manual assessment.
Breathing Pattern Assessment
In this video, Keats takes a look at Bret’s breathing patterns. He’s looking for natural diaphragmatic breathing that involves breathing into the belly prior to breathing into the thorax.
Head and Neck Mobility Assessment
In this video, Keats takes a look at Bret’s neck mobility from various directions. Normal ranges include 0-80-90 degrees of cervical flexion, 0-70 degrees of cervical extension, 0-30-45 degrees of cervical lateral flexion, and 0-70-90 degrees of cervical rotation.
Thoracic Spine Mobility Assessment
In this video, Keats takes a look at Bret’s t-spine mobility from various directions. Normal ranges are difficult to isolate since the t-spine is intimately connected with cervical and lumbar spine function. Suffice to say people need to be able to at least reverse the normal thoracic kyphosis to straight and be able to rotate at least 45 degrees in each direction from a tall seated position with the hips/pelvis stabilized. The T-spine is truly a huge player in full body movement capacity, breathing, and posture. Its influence on the c-spine (including the jaw/TMJ) and shoulders is often ignored in painful conditions.
Shoulder Mobility Assessment
In this video, Keats takes a look at Bret’s shoulder and scapular mobility from various directions. Normal ranges include 0-180 degrees of shoulder flexion, 0-60 degrees of shoulder extension, 0-180 degrees for shoulder abduction, 0-90 degrees of external rotation, and 0-70 degrees of shoulder internal rotation. Also included are basic length tests for pectoralis major, pectoralis minor, latissimus dorsi and teres major which to a large part determine the mobility in this region.
Hip, Ankle, and Big Toe Mobility Assessment
In this video, Keats takes a look at Bret’s hip mobility, ankle mobility, and big toe mobility from various directions. Normal ranges include 0-120 degrees of hip flexion (with bent knee), 0-90 with straight/extended knee, 0-30 degrees of hip extension (from prone position (knee extended), 0-45 degrees of hip abduction, 0-30 degrees of hip adduction, 0-45 degrees of hip external rotation, 0-40 degrees of hip internal rotation, 0-20 degrees of ankle dorsiflexion, 0-50 degrees of plantar flexion, 0-35 degrees of inversion, 0-15 degrees of eversion, and 0-65 degrees of big toe extension (although only 45 degrees are needed for gait). Also included is the thomas test for hip-flexor length. Not shown but extremely important is the “obers test” for hip-abduction contracture/tightness.
What do I do if Clients Don’t Possess Normal Ranges of Motion in Various Joints?
There are three basic scenarios that can occur with your assessments:
1) The individual will possess adequate ROM that doesn’t require any remedial stretching or mobilizations. For these people, a quality training/conditioning program will serve to maintain the range they already have. Semi-frequent re-testing is needed to make sure this range of motion isn’t lost however.
2) The individual has excessive ROM which may or may not be a problem depending on the strength and motor control capacities of the person. Too much ROM (hypermobility) can be just as bad in some situations as too little ROM! For specifically assessing if someone has too much ligamentous laxity/hypermobility all over their body, the Beighton Score is an easy testing protocol to administer.
3) The individual will possess decreased ROM/hypomobility in a given joint motion which could signify that either a musculo-tendinous/fascial or “extra-articular” (outside the joint) problem exists. Or, there could be a problem within the joint (intra-articular) that would required more attention to the joint capsule and other structures that would be best performed by a licensed professional trained to administer joint mobilization (Osteopath, physical/physio-therapist, chiropractor). This is a good reason for personal trainers and bodyworkers to have a good network of other professionals who can perform any specific joint work that might be needed. The basic goal with these people is to improve the range of motion of the truly short or stiff tissues. Utilizing the corrective strategies concept as promoted by the FMS, once lost ROM is regained, it must be backed up with some stability training (static, then dynamic stability) in order for it to stick. Stretching in and of itself is often not enough to change movement in any meaningful way!
A Hypothetical Scenario – Tight Hamstrings
Corrective exercise for a mobility restriction or stability problem is an art unto itself and would require an entire book (just read Gray Cook’s new book which should be available soon) to list all the various protocols. To give one example of a corrective sequence, let’s say that an individual has poor hamstring flexibility. Perhaps they are overworked from synergistic dominance due to weak glutes and tight hip-flexors on the other side. You would want to incorporate self-myofascial release for the hip flexors and activation work for the glutes in order to “release the brakes” on the hamstrings and decrease hypertonicity.
You would also want to incorporate various types of stretches and mobility drills for the hamstrings. Finally, you may want to start the client off with rack pulls and work on gradually increasing the range of motion until a full range deadlift can be perform while maintaining a neutral spine. Knowing various drills and progressions is critical in improving motor patterns and eliminating dysfunction. Assessments & Screens provide you with great information but you also need to know what to do with that information in terms of exercise selection and program design.
At any rate, we hope you enjoyed the videos. Over time, we will try to post more blogs that provide more information on screening and corrective exercise. Thanks for reading and watching!
-Keats Snideman and Bret Contreras