Active duty firefighters can improve Functional Movement Screen (FMS) scores following an 8-week individualized client workout program

Abstract

BACKGROUND: Firefighting is a dangerous occupation that requires adequate functional movement patterns to help reduce injury risk. Structured programs for improving movement quality have not been studied in firefighters.

OBJECTIVE: To examine the effects of an 8-week individualized corrective exercise training program on Functional Movement Screen (FMS) scores in active duty firefighters.

METHODS: Fifty-six male firefighters volunteered to participate in the study. All subjects completed baseline FMS testing and scores were entered into the FMS Pro360 system, subscription-based software which generates an individualized corrective exercise workout based on each independent test score. Two, 4-week corrective exercise programs were generated for each participant based on baseline testing. Following the 8-weeks, participants completed follow-up FMS testing.

RESULTS: A significant increase in total FMS score (pre = 12.09±2.75, post = 13.66±2.28) was found after the program. A significant increase in stability (pre = 4.13±1.21, post = 4.55±0.83) and advanced movements (pre = 4.45±1.28, post = 5.36±1.29) were also found, however, no difference was observed in mobility tests (3.52±1.09, post = 3.75±0.90).

CONCLUSIONS: The results suggest an 8-week individualized corrective exercise program was effective at improving scores on the FMS. Providing corrective exercise programs specific to improving levels of dysfunction or maintaining/enhancing function, may increase firefighter preparedness and attempt to minimize injury risk.

Keywords

Assessment corrective dysfunctional exercise training

1 Introduction

Firefighting is one of the nation’s most dangerous and hazardous jobs and among the highest occupations in incidences of cardiovascular death, physical and psychological stress, and muscular sprains and strains [1]. The demands of firefighting are considerably amplified with evidence showing the leading causes of job-related injuries are attributed to overexertion through physical and psychological strain and account for 47% of all on-duty injuries [2]. Occupational safety for fire-service personnel continues to be of primary concern, attributable to the emergent prevalence of these job-related injuries, morbidity and mortality. All firefighting and other rescue activities are dependent upon the physiological capabilities of firefighters. Firefighting, in training and on-duty, requires muscular strength, muscular power, muscular endurance, and more importantly high levels of cardiorespiratory fitness.

The estimated proportion of yearly time spent on firefighter duties has been shown to be 1–5% on fire suppression, 4–9% on alarm response, 7–15% on alarm return, 8% on physical training, 15–34% on emergency medical services and non-fire emergencies, and 29–65% on fire-station and non-emergency duties [3]. These allocated job duties provide insights into the demands placed on firefighters and the increasing peril accompanying these demands. The greater the demand imposed on firefighters, the potential accelerated risk of injury. The lack of maintaining appropriate health and fitness standards, particularly as a firefighter ages, as well as the deficiency in regular medical examinations by the firefighter departments, may also contribute to increases in cardiovascular and musculoskeletal risk [3]. Investigations by the National Institute for Occupational Safety and Health [4] showed that only 31% of the fire departments observed, where a previous cardiovascular fatality had occurred, had conducted annual or periodic medical evaluations, and only 8% required mandatory participation requirements in a structured fitness program. Firefighters are continuously exposed to the entire spectrum of environments requiring differential levels of physical activity, from sedentary to extreme, during job-specific performance tasks. These exposures provide a heightened environment for possible musculoskeletal incidents. As such, continual screening of firefighters for both musculoskeletal and cardiovascular risk becomes paramount.

One such screening tool that has gained in popularity among physical therapists, athletic trainers, strength and conditioning coaches and fitness professionals is the Functional Movement Screen (FMS) [5, 6]. The FMS has been a widely used pre-participation evaluation tool to identify levels of proficiency in seven fundamental movement patterns [5]. The FMS has been shown to be a reliable method for screening the physically active with interclass correlation coefficients ranging from 0.5–0.97 [7 –10]. The FMS was originally developed to help assess functional movement insufficiencies and asymmetries in the healthy population, [6] as well as to identify risk of injury. Additionally, tailored intervention programs could be designed to correct movement pattern dysfunction, and to create a baseline for observation through research [5]. The seven movements are scored individually using a 0–3 scale and the lower of the two scores is used towards the total on tests that can be performed bilaterally. A score of 0 is given if pain occurs during the movement. The inability to complete the movement or inability to assume the test position is scored as a 1, while completion of the movement with any type of compensation is scored as a 2. Finally, a score of 3 is given if the subject completes the movement correctly without compensation [5]. Previous research has identified a link between scores on the FMS and risk of sport injury [11 –15]. In addition, several studies [16 –19] have examined intervention programs aimed at improving scores on the FMS. However, the designs of the previous interventions have varied greatly. A relatively new software program (FMS Pro–360) was developed by the creators of the FMS and designed to assign tailored corrective exercises to each individual based on the FMS score. To our knowledge, no previous investigations have studied the effectiveness of using the FMS Pro–360 software program to improve FMS scores. Because many fire departments are unable to hire strength and conditioning professionals to improve their movement proficiency, this software could be a more cost-effective alternative for addressing movement dysfunction. Therefore, the purpose of this study was to examine the effectiveness of an 8-week individualized progressive corrective exercise program on FMS scores in a group of active duty firefighters.

2 Methods

2.1 Study design

The job-related physical skills required of a firefighter involve movement patterns that are highly associated with those attributed to the FMS: squatting, stepping, bending, pushing, and shoulder and spinal rotation. As such, a group of active duty firefighters were given the FMS and prescribed and 8-week corrective exercise program (independent variable) based on the FMS Pro360 system, which generates an individualized corrective exercise program. The firefighters were then re-administered the FMS (dependent variable) after 8 weeks to measure changes in their functional movement capabilities. Scores were reported and analyzed in several ways to determine the efficacy of the corrective exercise program. First, a composite score was calculated for the 7 tests by summing the final score for each assessment. Second, individual FMS tests were subcategorized into one of the following 3 categories: 1) Mobility, 2) Stability, and 3) Advanced movements. Mobility tests included the active straight leg raise (ASLR) and shoulder mobility (SM) assessment. Stability tests included the trunk stability push-up (TSP) and the rotary stability (RS) assessment. Advanced movements included the deep squat (DS), hurdle step (HS), and inline lunge (ILL). Final scores for each category were summed to determine a composite score for that category. Last, frequencies were reported for the number and percentage of subjects improving their final scores on each of the 7 tests from a 1 to 2, 1 to 3 and 2 to 3.

2.2 Subjects

Sixty, male, active-duty firefighters (age = 40.4±8.4 years, height = 178.5±11.2 cm, body mass = 97.6±19.4 kg, 14.8±7.8 years of service) volunteered to participate in the study. Subjects were recruited if they were 18 years of age or older; currently on active-duty assignment with the regional fire department; not being treated for any musculoskeletal injury; and not having have any medical conditions compromising participation in the study. Fifty-six firefighters completed all testing and met the inclusion and exclusion criteria throughout the duration of the study. Of the 4 that dropped out of the study, one suffer a fatal cardiovascular event, 2 had surgery and were no longer active duty, and 1 suffered an on the job injury and was referred for medical leave. Subjects were asked to maintain normal physical activity for the study duration. Each individual fire station provided an unsupervised, one-hour per shift allocation to complete the exercise program at a local health club. Based on station rotations, each individual was able to attend at least 3 sessions per 7-day cycle. The university’s institutional review board approved the study and all subjects received a clear explanation of the study, including the risks and benefits of participation, and written informed consent was obtained from all participants prior to testing. Subjects also completed a pre-participation questionnaire, identifying years of service as well as previous injury history.

2.3 Procedures

Participants interested in participating in the study were scheduled a date and time to complete the FMS testing. All testing was completed in the university’s exercise physiology lab during two separate visits, with the pre-test occurring during the two weeks prior to beginning the intervention program and the post-test occurring during the two weeks after the conclusion of the intervention program. During the first visit, participants were asked to read and sign the informed consent, and, if necessary, change into the appropriate attire. To ensure consistency, all subjects completed the movement patterns in athletic shorts, t-shirt, and unshod. The FMS, as described by Cook et al. [5], was used in the study. The FMS consists of 7 movement patterns to test mobility and stability. The 7 movements are the deep squat, hurdle test, in-line lunge, shoulder mobility, active straight leg raise (ASLR), trunk stability push-up, and rotary stability. All participants were read the same standardized instructions for each test and performed the movement patterns in the same order. Performances were video recorded by a research assistant (Canon Vixia HF-R10) from the sagittal and frontal views. Tape was placed on the floor to mark the location of the cameras and FMS test kit to ensure consistently throughout the data collection. The same 2 FMS certified evaluators separately scored both the pre- and post-tests and previous researchers have reported the reliability to be between 0.5–0.97 [7 –10]. In the event of a discrepancy between the two evaluators, consensus was achieved by each evaluator re-scoring the movement pattern and providing rationale for the decision until agreement for the final score was achieved.

Baseline scores for each participant were entered into a FMS Pro 360 account (Functional Movement Systems, www.functionalmovement.com). FMS Pro 360 is a subscription service that allows the management of client information, including the ability to input FMS scores and communicate with clients. This service also has the capability of automatically creating a set of corrective exercises for the participant based on the individual set of FMS scores. For each participant two, 4-week progressive corrective exercise training programs were generated. The logic used in generating the corrective exercises attempts to progress the individual from unloaded to loaded positions while prescribing movements that address limitations in mobility, followed by static motor control, dynamic motor control, and finally strength. The software first identifies limitations in mobility and chooses exercises to target the particular pattern. Motor control and stability tests are then addressed using the same procedure, followed by the advanced movements. The software provides an estimate for progression based on the movement pattern and alterations in exercise prescription typically occur after 8 workouts. Example programs for 2 subjects based on their baseline FMS scores are included in Tables 1 and 2.

Once all participant scores were entered and programs were created, an electronic copy of the individual program was emailed to each participant. Each fire station was visited twice during the week following the delivery of the programs to provide further instruction for how to use the programs and answer any questions related to the specific corrective exercise program. After the initial 4-weeks, the second corrective exercise program with progressions was electronically sent to each participant. Participants were asked to perform the prescribed program a minimum of 3 days per week and the corrective exercises were to be completed during their allotted physical activity time during their shift. All corrective exercises were performed and self-monitored by the participant during the 8-weeks. At the conclusion of the 8-weeks, participants reported back to the exercise physiology lab to complete FMS post-testing using the exact same procedures describedabove.

2.4 Statistical analyses

Descriptive statistics (frequencies, means, and standard deviations) were calculated for select variables. Mann-Whitney U tests were performed to determine statistically significant differences between pre- and post-scores. Significance level was set a priori at p < 0.05.

3 Results

Descriptive statistics are presented in Tables 3–5. A significant improvement in total FMS score was found following the 8-week intervention program [(pre = 12.09±2.75, post = 13.66±2.28), U = 984.5, z = –3.43, p = 0.001, effect size = 0.62]. No significant difference was found between mobility tests [(pre = 3.52±1.09, post = 3.75±0.90), U = 1394.5, z = –1.06, p = 0.29]. A significant difference was found between both stability [(pre = 4.13±1.21, post = 4.55±0.83), U = 1268, z = –1.99, p = 0.046, effect size = 0.40], and advanced movements [(pre = 4.45±1.28, post = 5.36±1.29), U = 942.5, z = –3.74, p = 0.001, effect size = 0.71)]. Following the 8-week intervention, 65% of participants improved their advanced movement scores, while 55% and 58% improved their mobility and stability scores respectively.

4 Discussion

The purpose of this study was to examine the effectiveness of an 8-week, personalized corrective exercise program on FMS scores in active duty firefighters. Results from this study suggest an 8-week corrective exercise program was effective at improving total FMS scores as well as both stability and advanced movement scores in a group of active duty firefighters. To our knowledge, this is the first study to examine the effectiveness of the FMS Pro 360 corrective exercise program. These results were consistent with previous intervention studies on an active population [17, 18].

The Functional Movement Screen has received considerable attention as a tool to screen fundamental movement patterns and is commonly used as part of a pre-participation evaluation. The majority of this attention has examined the total scores of participants and attempted to correlate scores with increased risks for injury. Often total FMS scores of ≤14 are associated with an increased risk of injury and studies from professional football players, soldiers, and firefighters have demonstrated the ability to prospectively identify individuals at risk for sustaining a musculoskeletal injury [11 , 21]. While it is important to prospectively identify at-risk individuals, it is equally important to determine ways to improve potential faulty movement patterns, as indicated by scores of 1, in an attempt to minimizeinjuries.

Recently, studies have begun to focus on improving scores through the use of corrective exercises or off-season training programs. While considerable attention continues to be given to the total FMS score, and specifically scores of ≤14, it is possible to achieve a score of >15 while still having dysfunctional movement patterns. Effective intervention programs should address asymmetries and fundamental movement pattern dysfunctions, with the focus on progressing from deficits in mobility, followed by stability, and lastly advanced movement patterns. Furthermore, effective interventions should have the ability of improving individual dysfunctional movement patterns (score of 1) to a more functional pattern (scores of 2 or 3), in an effort to decrease injury risk. Five [16–19 , 22] previous studies have examined the modifiability of the FMS with various types of interventions with 4 [16 –19] showing positive effects on the FMS. Bodden et al. [18] studied an intervention program in mixed martial arts athletes and found significant improvements in total FMS score following a 4-week individualized intervention, but no additional improvements in FMS scores between weeks 4–8 of the program. This was one of the first studies to use a control group and mid-intervention test to determine the effectiveness of the program. Additionally, these data showed significant improvements in the intervention group for improving asymmetries after both 4 and 8 weeks of corrective exercises. Unfortunately, data was not provided to determine numbers of subjects improving scores on each individual test or based on the mobility, stability, or advanced movement classification. Similarly, Frost et al. [19] examined 2 different intervention programs and compared to a control group in a sample of firefighters but found no differences in FMS scores in either intervention group. Intervention group 1 focused on whole body coordination and control while intervention group 2 aimed to make the firefighters as fit as possible. While the findings of these two previous studies were conflicting, our results, and individualized intervention program, align with the findings of Bodden et al. [18]. This current study, as well as the Bodden et al. [18] study, used the individual’s pre-test FMS score to determine the corrective exercises included within the intervention. It is plausible the differences in findings from those of Frost et al. [19] could be attributed to the intervention program selection.

Three other studies [16 , 23] have examined the effects of an intervention program on FMS scores. Kiesel et al. [17] examined the effectiveness of an off-season training program on FMS scores in professional football players. At the end of the intervention, a greater number of players improved their scores above the injury threshold (≤14) compared with before the intervention. This study also showed a significant change in number of athletes free from an asymmetry from before to after the off-season program, but still failed to demonstrate effectiveness of improving faulty baseline movement patterns. Cowen [23] examined FMS scores in a group of firefighters before and after a 6-week yoga program and found significant improvement in participants’ total FMS score. Goss et al. [16] measured FMS scores in a group of special operations soldiers following a 6-week functional training program and found improvements in total score by approximately 2.5 points. Our findings were consistent with these two previous studies, although not to the same magnitude. We saw participants improve their total score by approximately 1.5 point while previous investigations have shown improvements by 2.5 to over 3 points. Interestingly, our study also showed slightly lower total FMS scores than previous investigations using firefighters [19 , 24].

There are many possible reasons for the discrepancies between our findings and previous studies examining intervention programs. First, our subjects, on average, were older and displayed lower composite FMS scores than comparison studies. It is possible the level of dysfunction and years of engrained faulty motor patterns in our participants caused a slower response to the intervention. Second, three of the previous studies that showed significant differences in FMS scores as a result of an intervention were all conducted on a population that could be more accurately described as athletes (mixed martial arts, military personnel, professional football players). Ironically, the two remaining studies were both conducted on firefighters with conflicting results. Firefighting is an extremely demanding occupation and successful firefighters need to be both athletic and physically trained. However, a comparison of the demographic information from the Frost et al. study showed our subjects were slightly shorter with greater body mass (178.5±11.2 cm, 97.6±19.4 kg vs. 180±6 cm, 90.3±14.3 kg). Despite Frost et al. not showing improvements in FMS scores, the two interventions were not individualized, nor specifically tailored to improving FMS scores. Unfortunately, height and body mass information was not provided by the Cowen study.

Overall, the results from the current study support previous investigations and provide some evidence for improvements in not only overall score, but more importantly, improvements in scores originally evaluated as a 1. The results from our study showed 54.1% (46/85) of individuals that scored a test score of 1 in an advanced movement test improved to either a score of 2 or 3 after the 8-week corrective exercise program. Similarly, 45.5% (15/33) of participants improved their dysfunctional (score of 1) mobility scores, while only 10% (2/20) improved their stability scores. However, it should be noted that a greater number of participants initially demonstrated dysfunctional mobility patterns compared with stability. In contrast, of those individuals that showed movement competency (a score of 2), 10.8%, 9.6% and 14% improved to a score of 3 for the advanced movements, mobility and stability scores respectively. On the contrary, some subjects did digress following the 8-week intervention. These results showed 5.4% (9/168) of the firefighters had lower scores on the advanced movements, 16.1% (18/112) on the mobility, and 3.6% (4/112) on the stability tests. While these results were discouraging, we could only speculate for why this occurred.

Firefighting is a demanding, whole body activity that places stress on individual firefighters in many different ways. The results of this study showed an 8-week intervention was able to improve stability and advanced movement scores on the FMS, but not overall mobility. One possible explanation for this dichotomous result could be how the programs were fit into their daily routine. During each shift, the firefighters were given one hour to go to a local fitness facility to work on their physical fitness. The department provided no programming and firefighters were able to develop their own workout routines. During the 8-week intervention, firefighters were asked to begin their workout with the corrective exercise program and use the remaining time to complete their normal workout routines.

This study had several inherent limitations that warrant discussion. First, subjects were provided their individual training programs and given the opportunity to ask questions about how to perform the movements. However, there was no one physically present during each exercise session to ensure the corrective exercises were being performed as prescribed. The study was designed with this limitation as it was felt independent exercise practice was more practical for how programming would be applied to this population based on the nature of the firefighters’ schedules, fluctuations in the allotted one-hour time provision, and the budget constraints facing many cities and town to employ qualified supervision. Second, participants were asked to maintain their current level of activity both on-duty and off-duty, however, there is no way of ensuring the individualized training programs did not affect their choice in activity participation. Lastly, our study did not use a control group. Participants and examiners were not blinded to the pre-intervention data and it is possible they remembered what they scored previously and that could have affected the post-test, however this was minimized by averting any feedback on test instruction and scoring to participants.

4.1 Practical application

The results from this study identify the benefits of a structured corrective exercise program for firefighters, but more importantly a program that accounted for and addressed dysfunction in an individual’s fundamental movements. The musculoskeletal demands imparted on a firefighter to complete on-duty tasks places those individuals at increased risk development of physical dysfunction and thus increasing the potential for injury. Analysis for moderate and severe firefighter fireground injuries for the 2007–2011 revealed an estimated annual average of 5,255 injuries, or 52% of all moderate or severe injuries, occurred at structure fires during activities related to extinguishing a fire, 4,130 (78.6%) of these occurred while handling charged hose line. In addition, an annual average of 2,520 injuries, or 25%, occurred during suppression support activities, an average of 910 occurred during other incident scene activities, and an average of 370 occurred during rescue activities [25]. While not all injuries are avoidable, this information shows that heightened physical preparation is a necessity for firefighters to not only perform their duties adequately, but minimize injury potential. The results from this study show the benefits of prescreening individuals for musculoskeletal dysfunction, particularly those undergoing the rigors of firefighting. Providing progressive corrective exercise programs specific to improving levels of dysfunction or maintaining/enhancing function, can increase the physical preparedness of a firefighter and attempt to minimize injury risk as much as possible.

Conflict of interest

None to report.

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