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DOI: 10.1519/JSC.0000000000001943
The relationship of core strength and activation and performance on three functional
movement screens
Running Head: Relationship of core strength and three functional movement screens
Authors:
Caleb D. Johnson a
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Paul N. Whitehead a
Erin R. Pletcher a
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Mallory S. Faherty b
Mita T. Lovalekar a
Shawn R. Eagle a
Karen A. Keenan a
a. University of Pittsburgh, Neuromuscular Research Laboratory, 3860 South Water St.,
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Pittsburgh, PA 15203
b. Michael W. Krzyzewski Human Performance Laboratory, Duke University, DUMC
102916, Durham, NC 27705
Fax: 412-246-0461
cdj20@pitt.edu
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Funding Source:
We would like to acknowledge the Freddie Fu, MD Graduate Research Award for funding this
project
ABSTRACT
Current measures of core stability utilized by clinicians and researchers suffer from several
ability to activate and control core musculature. These three screens may present a viable
alternative to current measures of core stability. Thirty-nine subjects completed a deep squat,
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trunk stability push-up, and rotary stability screen. Scores on the three screens were summed to
calculate a composite score (COMP). During the screens, muscle activity was collected to
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determine the length of time that the bilateral erector spinae, rectus abdominus, external oblique,
and gluteus medius muscles were active. Strength was assessed for core muscles (trunk
flexion/extension, and pectoralis major). Two ordinal logistic regression equations were
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calculated with COMP as the outcome variable, and: 1) core strength and accessory strength, 2)
only core strength. The first model was significant in predicting COMP (p=.004) (Pearson’s Chi-
Squared=.362). The core muscles were found to be active for the majority of screens, with
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percentages of “time active” for each muscle ranging from 54%-86%. In conclusion,
performance on the three screens is predicted by core strength, even when accounting for
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“accessory” strength variables. Further, it appears the screens elicit wide-ranging activation of
core muscles. While more investigation is needed, these screens, collectively, appear to be a
INTRODUCTION
Core stability can be defined as the ability to achieve and sustain control of the trunk and
hip regions at rest and during precise movement (12, 22). Core stability is accomplished through
the trunk and hip musculature (12, 22). This inherent complexity results in a lack of consistent
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measurement for core stability across studies. Most objective tests aimed at quantifying core
stability are limited as they either: (a) only measure one aspect of this complex interaction, such
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as core strength or (b) assess a more complete picture of this interaction, but in positions that are
functionally irrelevant when the proposed role of core stability during dynamic movement is
considered (3, 12, 19, 20, 29-31). Subjectively scored tests seem to suffer the same shortcomings
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as objective tests, along with poor inter- and intra-observer reliability (27-29). To summarize, it
would seem that a more comprehensive and reliable measure of core stability is needed; both for
A test that may better address the multi-dimensional nature of core stability is the
Functional Movement Screen (FMS). This screen involves the subjective scoring of seven
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different patterns aimed at identifying functional deficits in strength, balance, flexibility, and
neuromuscular control. Several studies have suggested that the FMS Composite score is
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associated with musculoskeletal injury in collegiate and professional athletes, however the
overall predictive value of the screen has been called into question in recent literature (1, 5, 16,
17). Despite this, the important aspects of the FMS, in relation to the current study, are their
possible application to assessing core stability. Secondly, while the screens are scored
subjectively, they have been shown to have good inter-tester and inter-session reliability (4).
Three of the seven movement screens, the Deep Squat (DS), Rotary Stability (RS) and
Trunk Stability Push-up (TSP), are specifically aimed at assessing core stability and involve
dynamic tasks in all three planes of motion (frontal, sagittal, and transverse). Additionally, the
screens assess the core musculature’s ability to keep the lumbopelvic complex in a neutral
position, which has been shown to be optimal for loading of the trunk without sustaining injury
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(12, 29). These three screens would seem to hold good face-validity in assessing functional core
stability, however their relationship to components of core stability have not been established.
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The purpose of the current study was to investigate the relationship between performance
on the DS, RS, and TSP screens (referred to as FMS-3 moving forward) and components of core
stability. First, we examined the relationship between performance on the three screens and
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isokinetic strength of the trunk and hip musculature (core muscles) compared to other
musculature (accessory muscles) that may play a role in successful completion of one or more of
the screens. We hypothesized the performance on the screens would be predicted by core muscle
strength and that core muscle strength would explain a greater amount of variance in FMS-3
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performance than strength of the accessory muscles. Second, we assessed whether the screens
hypothesized the three screens would elicit widespread activation of the core musculature. If in
the expected direction, the results of this study would provide evidence for the use of the FMS-3
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as a viable measure of core muscle function. Further, they would provide justification for further
METHODS
Subjects completed all testing on the same day, including: completion of the FMS-3 while core
muscle activity was collected; isokinetic strength for trunk flexion/extension (TFS/TES),
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bilateral trunk rotation (TRS), and bilateral knee flexion/extension (KFS/KES); and isometric
strength for bilateral hip abduction/adduction (HABS/HADS) and the pectoralis major group
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(PMS). Core strength variables were selected based on common definitions of the core region
found in previous literature (12, 29). Accessory strength variables were selected based on our
assessment of the FMS-3 and what muscle groups may also play a role in performance of them.
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Pectoralis major strength was included due to the pectoralis major’s role in extension of the arm
and horizontal adduction of the humerus during the TSP. Knee flexion/extension strength was
included due to the hamstrings role in knee flexion, and the quadriceps role in knee extension
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during the DS screen. Further, co-contraction of the hamstrings and quadriceps is thought to be
important for maintaining the knee joint in a neutral position, one of the criteria the DS screen is
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scored on (10). Order of testing for the FMS-3 and trunk strength measures was block
randomized.
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Subjects
Eighteen males (Age= 22.22 ± 2.32 years, Weight= 77.24 ± 6.70 kg, Height= 179.94 ±
8.89 cm) and 21 females (Age= 22.36 ± 3.58 years, Weight= 61.12 ± 8.28 kg, Height= 165.62 ±
7.00 cm) were recruited from an athletic population, with the criteria of having participated in an
organized, land-based sport within the past year. Further, the sport had to involve dynamic
movement with changes of direction (i.e. soccer, basketball, volleyball etc..). Subjects were
excluded based on: 1) current musculoskeletal injury or pain, or injury in the past three months,
2) musculoskeletal surgery in the past three years, 3) concussion in the past three months or the
presence of neurological disorders, 4) recent history of screening with the FMS. Musculoskeletal
injury was defined as any impairment that resulted in a limitation to participation in sport,
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training or activities of daily living for more than a week. Approval by the Institutional Review
Board at the University of Pittsburgh and informed consent by individual subjects was obtained
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before any testing procedures were carried out.
Procedures
(EMG) (Noraxon USA, Scottsdale, AZ). Muscle activity was recorded bilaterally for the erector
spinae (level of L3), external oblique, rectus abdominis, and gluteus medius. Placement sites for
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each muscle were determined based on SENIAM recommendations (7) and Cram & Kasman
(13). Sites were prepared based on SENIAM recommendations (7) and two bipolar Ag/AC-CI
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electrodes (AMBU Blue Sensor N electrodes; ABMU, Glen Burnie, MD) were applied to each
site, parallel to the muscle fibers and approximately 2 cm apart. Electrodes were attached to
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wireless transmitters and placement sites were verified with submaximal contractions prior to
electrodes and transmitters being secured with adhesive tape and cover-all (3M Health Care Ltd.,
Loughborough, UK). A sitting “quiet-trial” was collected to assess the respective resting levels
of muscle activity. A sampling frequency of 1000 Hz was used for all EMG data collection.
The FMS-3 were performed by subjects according to the standardized procedures and
scripts described by Cook (2) and in previous studies (16). The only alteration made to the
screening procedures was to give subjects a countdown before each screen for the purposes of
synchronizing surface EMG data collection. Each screen was scored on a scale of 0-3 points,
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however a score of zero indicates pain was experienced with the respective movement for a
given screen. Since no subjects experienced pain with screening, the scoring for each screen was
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effectively reduced to a scale of 1-3. Screens were administered and scored live by an FMS
certified rater with ample experience. For a sub-sample of subjects (n=29), screens were also
recorded with a digital video camera and then scored a second time, after a minimum of 2
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months, and the inter-rater reliability for the scoring is described below. For muscle activity, data
collection was initiated approximately two seconds before the subject initiated the specific
movement for each screen and was terminated when the subject reached the end-point defined
All isokinetic strength testing was completed on the Biodex System 3 (Biodex Medical
Subjects were positioned and stabilized according to the manufacturer guidelines, and three
practical/warm-up trials were given at 50% of perceived maximal effort and 100% of perceived
maximal effort. Following a 90 second rest period, subjects completed five trials at 100% effort
for analysis. Isokinetic testing on the Biodex System 3 has shown good reliability and precision
(6).
A hand-held dynamometer (Lafayette Instrument Co., Lafayette, IN) was used for all
isometric strength testing. Positioning of the subjects and testers was based on manual muscle
testing procedures outlined by Hislop & Montgomery (11), and testing procedures were based
off of established and reliable protocols in past literature, which have also been shown to be
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reliable (ICC=.76-.989) through previous testing in our lab (15, 26). Hip abduction/adduction
strength and SADS were collected using “make tests”, where subjects were asked to push
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maximally against the hand-held dynamometer and testers matched the force being exerted by
the subject. A 50% warm-up was given for each movement and two or three trials, depending on
if the first two were within 15% of each other, were collected at 100% effort for analysis.
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Data Reduction
A composite score (COMP) was calculated for the FMS-3, out of a possible 4-12 points,
by summing the four individual scores from each screen. The RS screen is performed separately
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on either side of the body, therefore the left and right scores were added into the COMP
separately. Isokinetic strength was represented as the average peak torque across the five
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consecutive contractions for each movement. Isometric strength was represented as the average
of either two or three maximal trials, dependent on the consistency of trials. Averaging across
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bilateral limbs was appropriate given that none of the movement patterns tested involved
unilateral movements. Further, this limited the number of independent variables in the calculated
regression equations.
A custom Matlab program (Matlab R2014a, MathWorks, Natick, MD) was used for
EMG data reduction. All EMG data were rectified and filtered through a 16-500 Hz band-pass
filter. Each trial was cropped to reflect the extra two seconds of data collection prior to the
initiation of a movement by the subject. The level for a muscle being “active” was defined as
three standard deviations above the mean amplitude of the signal during the quiet trial. The
percentage of time that each muscle was active for each screen was calculated by dividing the
time that each muscle met the above criteria for being “active” by the total trial time. Data were
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averaged for bilateral muscle groups and across the three screens, following similar logic as
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Statistical Analyses
All statistical analyses were conducted using IBM SPSS Statistics 23 (IBM, Armonk
NY). Descriptive statistics were calculated to examine the central tendency and variability for
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percentage of time that core muscle groups were active across the three screens. Frequencies
were calculated for COMP. Reliability coefficients (intra-class correlation coefficients and
Cohen’s Kappa statistics) and percent agreements were calculated to assess the scoring reliability
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Two ordinal regression equations were developed to assess the prediction of COMP by
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core muscle strength. Strength variables were checked for normality by visual inspection of
calculated to assess the inter-correlation among strength variables, and Spearman’s Rank
Coefficients were calculated to assess the bivariate correlation among strength variables and
COMP. Strength variables were eliminated based on concerns of multi-collinearity as well as the
strength of their bivariate correlation with COMP. The first ordinal regression equation
contained both core (TRS, HABS, HADS) and accessory (KFS, PMS) strength variables. To
compare the relative reduction in explained COMP variance, the second equation only contained
core strength (TRS, HABS, HADS) variables. Level for significance was set at α<.05 for all
tests.
RESULTS
COMP scores were found to be effectively reduced to a scale of 6-10, however the range
of scores within the reduced scale was evenly distributed: 6 (20.5%), 7 (25.6%), 8 (15.4%), 9
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(17.9%), 10 (20.5%).
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Core Muscle Activity
Descriptive statistics for core muscle activity during the FMS-3 is presented in Table 1.
The sample size for muscle activity data was reduced (n=38) due to issues with Surface EMG
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equipment causing one subject’s data to be discarded. The measured core muscles were found to
be active for the majority (>50%) of the screens. The gluteus medius showed the greatest percent
activation (86.2 ± 10.6%), and the rectus abdominis showed the lowest (54.9 ± 12.8%).
Reliability coefficients for the scoring of individual FMS and the COMP are presented in
Table 2. All screens were found to have sufficient reliability (Cohen’s Kappa = .635-.887) except
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for the Left Rotary Stability screen (Cohen’s Kappa =.018). This low reliability coefficient can
be attributed to a lack of variability in the scorings, with a high number of subjects scoring a two
on the screen. Supporting this assertion is the high percent agreement between scorings
(93.10%). Composite score showed excellent reliability (ICC 2,1 = .917) and percent agreement
(72.41%).
Bivariate correlations between strength variables and COMP are presented in Table 3.
The full results of the 1st and 2nd ordinal regression equations are presented in Tables 4 and 5
respectively. The full set of predictors showed significance in predicting COMP for both models,
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and the relative amount of variance explained by the models, denoted by the Pseudo R- Square
values, was similar (.369 to .362). Finally, TRS was the only significant independent predictor of
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COMP for both models.
This manuscript details the relationship between performance on the FMS-3, and
activation and strength of the core musculature. It was hypothesized that performance on the
screens would be predicted by core muscle strength and that core muscle strength would explain
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a greater amount of variance in FMS-3 performance than strength of the accessory muscles.
Further, it was hypothesized that the three screens would elicit widespread activation of the core
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musculature.
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on the FMS-3. While the grouping of core strength and accessory strength variables were also
significantly predictive of FMS-3 performance, the Pseudo R-Squared values were highly similar
between the two equations. While Pseudo R-Squared values cannot be interpreted as the exact
percentage of variance in outcome variables explained by the predictor variables, they can be
interpreted relative to another Pseudo R-Squared value calculated on the same data set (21).
Therefore, the minimal difference in values with the elimination of accessory strength variables
can be interpreted as the core strength variables explaining significantly more variance in
COMP.
Few studies have assessed the relationship of performance on the FMS and core muscle
function. Our results are in-line with prior research by Mitchell et al. (24), showing moderate
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correlations between core muscle endurance measures and composite score on the full FMS
battery. However, correlations were not reported for performance on individual screens, giving
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these results little applicability to the current study. Our results are counter to those reported by
Okada et al. (25), showing no correlation between core muscle endurance and individual
performance on any of the FMS. Given the short duration of the screens and quick nature of the
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perturbations they provide to the core, it is not overly surprising that correlations were not found
with endurance of the trunk musculature. It would seem natural that trunk muscle strength, which
was measured in the current study, would be a stronger predictor of performance on these
screens.
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Trunk rotation strength was the only independent predictor of COMP in either of the
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models. This result should be interpreted with caution however, given the number of variables
that could not be entered into the equation (KES, TFS, TES) due to multicollinearity among the
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strength variables. Further, TFS and TES (in discussing only the core strength variables) both
showed significant, moderate correlations with COMP (Table 3). However, TRS did show the
highest bivariate correlation (R =.547) with COMP. A possible explanation may be that the
performance of the TRS isokinetic testing elicited recruitment of smaller, deeper muscles,
sometimes termed local stabilizers (8). These muscles are thought to play a larger role in core
stability during low-load conditions; a designation applicable to the screenings included in this
study. In contrast, the TFS/TES isokinetic testing fixes the spine in a more rigid position, and
therefore may predominantly elicit recruitment of the larger, more superficial muscles that
It was found that the core muscles, including the erector spinae, rectus abdominis,
external obliques, and gluteus medius were active for the majority of the FMS-3. The rectus
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abdominis were found to be active for the lowest percentage of time, at 54.9% of total screening
time. This may have been partially attributed to the adverse effects of increased adipose tissue
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around the abdominal area on EMG signals. However, Hamlyn et al. (9) reported no significant
increases in lower abdominal muscle activity between trunk stabilization exercises and normal
resistance exercises. Further, Marshall et al. (23) showed mixed results when assessing
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differences in rectus abdominis activity between exercises performed on a stable and unstable
surface. Therefore, it is also possible that the rectus abdominis does not play a vital role in core
stabilization. Further work would be needed to confirm this, however, therefore the current
results can only lead us to conclude that the FMS-3 elicited to lowest activity from the rectus
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abdominis group.
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The range of scores was found to effectively reduce the COMP scale from 4-12 to 6-10.
While it could be that subjects whose abilities fall on either end of the spectrum were simply not
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obtained in the study sample, the subjects recruited ranged from recreational to Division I
athletes. A better explanation would seem to be that alterations are needed in the scoring of
several of the screens to make them more sensitive to a competitive athlete population and more
specific to measuring stability of trunk and hip regions. The vast majority of subjects (82%)
scored a two on the RS screen, in both directions. The scoring criteria for the RS screen is based
on successful completion of a repetition, where the non-moving hand and foot remain in contact
with the testing board (2). Adding criteria that places a focus on control of the movement, may
delineate between individuals who can simply perform the motion and those who can perform it
without excessive movement through the trunk and hips. In contrast, the DS screen is scored on a
number of criteria, including depth of the squatting motion, alignment of the lower extremities,
and position of the trunk and dowel rod relative to the hips (2). Altering the scoring of this screen
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to be primarily dependent on control and position of the trunk and hips throughout the movement
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There are several limitations to the current study. While the subjective scoring of the
FMS has been shown to have fair to excellent reliability in several studies, the results have been
mixed, with several studies showing poor reliability (4). In general, the reliability of FMS
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scoring has been favorable and further, the inter-session reliability for the rater used in the
current study was shown to be adequate for all screens (4). Another limitation inherent to the
FMS, identified in recent literature, is a lack of internal consistency among the seven screens,
indicating that these screens are not measuring a single construct (14, 18). One could argue that,
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although the FMS is meant to assess overall movement quality, the individual screens are
intended to measure different aspects of overall movement quality, possibly accounting for this
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lack of internal consistency. This limitation has more implications for the use of the composite
score on the complete FMS, however it establishes a need to assess the internal consistency of
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A second limitation lies in the generalizability of the reported results, with the study
sample only including competitive athletes. Our reasoning in recruiting the current sample was
that the role of core stabilization is likely different for individuals with varying levels of athletic
skill and overall physical activity. Therefore, the relationship between the variables included in
The most important limitation is in the interpretability of the main analyses; delineating
between core strength and core stability. As was stated before, proper core stability is a product
of a complex interaction of core muscle strength and endurance, neuromuscular coordination and
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control, and proprioception (12). Based on this model, the interpretation of the results is limited
to the relationship between one component of core stability (core strength) and performance on
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the FMS-3. Further, while core muscle activation was measured, the level of activation, in terms
of a percentage of each subject’s maximum volitional contraction, was not. Therefore, the
interpretation of the reported muscle activity should be limited to a confirmation that the core
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muscles were active for a significant portion of the FMS-3.
In conclusion, the results of this study show a relationship between core muscle strength
and performance on the DS, RS, and TSP screens taken from the FMS. Further, the screens were
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found to elicit widespread activation of the core musculature. While several alterations to the
screens and their scoring may be required, our results provide evidence that these three screens
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are a viable and clinic-friendly measure of core muscle strength. Broadening the focus of the
current study, future research is needed to determine the relationship of performance on these
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PRACTICAL APPLICATIONS
The results show that performance on the DS, RS and TSP screens from the FMS are
capturing some aspect of core strength and core muscle activation. Further, they show that
scoring on these three screens, as well as the COMP score computed by adding the individual
scores together, can be done reliably within a single tester. These three screens take several
minutes to administer and require very little, as well as low-cost, equipment. The practical
applications of the current study, then, center on providing evidence for this battery of screens
that can be easily utilized by clinicians in assessing their client’s ability to stabilize the trunk and
hip regions during dynamic movement. While several limitations to the interpretation and
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generalizability of our results are present, our results still provide compelling evidence that this
is the case.
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ACKNOWLEDGEMENTS
We would like to acknowledge the Freddie Fu, MD Graduate Research Award for
(n=38)
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External obliques (% active) 74.98 ± 11.70 48.69 89.57
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% active= percentage of time the respective muscle was active across the three screens,
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Right Rotary Stability 2.03 2.10 .635 93.10
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Composite Score 8.00 8.24 .917* 72.41
*- denotes intra-class correlation coefficient (ICC 2,1); all other reliability coefficients
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are Cohen’s Kappa statistics
% Agreement= percentage agreement between 1st and 2nd scorings of respective screen or
composite score
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Trunk Flexion Strength .494*
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Knee Flexion Strength .499*
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Model -2 LL df p-value Pseudo R-Squared: .369
Null 107.369
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General 95.255 15 .670
df= degrees of freedom; -2 LL= -2 Log Likelihood; IO= intercept only; F=final; SE=
standard error
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Model -2 LL df p-value Pseudo R-Squared: .362
Null 107.795
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General 97.104 9 .297
df= degrees of freedom; -2 LL= -2 Log Likelihood; IO= intercept only; F=final; SE=
standard error
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