Those of you who are seasoned fitness professionals are likely aware of the multitude of standardized formats you can use to screen movement in a client to identify potential issues related to gait, agility, balance, and movement patterns. The Functional Movement Screen® is perhaps one of the most popular, with a variety of tests that can be scaled and adapted to the needs of the clients.

            Today I am going to go over how I assess movement in clients, identify potential problems, and we will talk about when to refer out to another qualified movement or healthcare professional. The primary purpose of this screening methodology is to first keep the client SAFE during exercise. The secondary purpose is to gather movement data that is related to Activities of Daily Living (ADLs) so that baseline function can be established.

            This movement screening is designed to test the client on movements they perform every day in their lives at work, home, and play. It is intended to be simple, easy to execute and scale to the client, and be reliable.

Step 1 – Health Risk Assessment

            Before you have the client perform a single movement screen, you should take care of their initial Health Risk Assessment, using the PAR-Q+ form which is standard for our industry. The results of the PAR-Q+ will determine whether you need physician clearance or you can proceed with intake and screening.

Failure to do this first is outright negligent and incompetent, as well as disregards industry best practices. You should assess blood pressure and heart rate as well, since both will become elevated during testing and if the client has a high BP or HR prior to assessment, caution may need to be taken to prevent injury or illness.

Step 2 – Warmup

            Prior to beginning movement assessment, ensure you take the client through a proper warmup. This warmup should slightly raise core temperature, increase peripheral perfusion (blood flow to the extremities), increase soft tissue pliability, and raise the client’s mental awareness of their body. Usually 10-15 minutes at a moderate intensity on a treadmill or elliptical machine is sufficient for warmup. Light stretching should be done only if absolutely necessary, as stretching prior to resistance training has been shown to reduce power output and, in some cases, reduces joint stability.

Step 3 – Bodyweight Squat

            First, instruct the client to perform a bodyweight squat in the manner that is most comfortable for them. You are not cueing proper technique yet, but rather are observing the client’s existing movement patterns and technical proficiency. They should perform several slow reps with full control that you view from the front, side, and back to gain an accurate picture of their unloaded squat.

• Observe for tracking of the knees straight across the top of the feet.
• Look for the hips being pushed back into space as the client hinges at the hip and closes the hip joint angle as they descend into the squat.
• Observe the head position: does it remain neutral or does the client extend or flex the neck during any portion of the squat?
• Observe the lumbar spine: does the client preserve their natural curvature through the squat, or does the lumbar spine extend as the client ascends?
• Observe the feet: do they stay firmly rooted to the ground with 3 points of contact (ball of the big toe, ball of the pinky toe, heel)? Is there inversion or eversion present?
• Observe the entire movement: does the client simultaneous flex the ankles, knees, and hips as they descend? Does the client exhibit simultaneous extension of the ankles, knees, and hips as they ascend?
• Observe balance: does the client shift weight left or right, front or back as they perform the squat?

Step 4 – Hip Hinge

            Demonstrate a proper hip hinge (Romanian deadlift position) to the client, and then instruct them to perform the hip hinge motion several times slowly. Feet should be under the client’s shoulders either straight forward or slightly externally rotated.

• Observe the hips: do they push back into space and does the hip angle close while the knee flexes slightly? Does the client push the hips back under the shoulders (a cue) when they ascend?
• Observe the knees: knee flexion should be limited to roughly 30-45 degrees (will depend on the client’s existing hamstring mobility)
• Observe the head: does it remain neutral or go into flexion or extension during the movement?
• Observe the thoracic spine: is there any extension as the concentric portion of the movement begins?
• Observe the lumbar spine: does the client preserve their natural curvature or do they extend at the low back as they ascend?
• Observe the spine from an anterior or posterior view: is there any lateral deviation in the client’s spine that would indicated L/R compensations during the hinge?

Step 5 – Rowing Movements

            Demonstrate a proper face pull and mid row using either a cable machine or resistance band for the client, and then have them perform several repetitions of each under light load with a slow tempo.

• Observe the arms: is the client beginning the row by driving the elbow down to the hips?
• Observe the shoulder blades: do they move in unison or is one “slower” than the other? Do they excessively protract at the end of the eccentric phase?
• Observe the shoulder blades: does the client exhibit strong scapular retraction at the bottom of the row, or are they lacking scapular retraction?
• Observe the humerus: does the client attempt to force the upper arm into extension when they pull, or do they stop with the humerus in line with the torso?
• Observe the spine: does the client maintain core bracing with a neutral spin, or do they flex their spine during the eccentric phase or extend the spine during the concentric phase?

Step 6 – Chest Press

            Demonstrate a proper chest press using light dumbbells well within the client’s strength range on a flat bench. Instruct them in how to arch their back and retract their shoulder blades to create a solid foundation for the press properly and safely. If creating the lumbar arch for the press is uncomfortable for the client or they have preexisting lumbar pathology, have them place their feet up on the bench with the knees mostly or fully flexed. This will place the pelvis into either a neutral or posterior tilt position, removing compressive stress from the discs and vertebrae.

• Observe the shoulders: does the client generate shoulder stability through retraction of the shoulder blades and lats during all portions of the movement?
• Observe the humeral abduction angle: does the client keep their upper arm abducted to roughly 45 degrees to keep the humeral head centrated in the glenoid fossa and recruit the pectoralis effectively?
• Observe the depth of shoulder extension: does the client stop when the dumbbells reach chest height, or do they attempt to lower the weights deeper?
• Observe the shoulders at the top of the press: is the client protracting their shoulders or keeping them locked and stable?
• Observe the arms: does the client move their arms in sync with each other? Are there obvious deficits in stability and control?
• Observe the pelvis and legs: does the client keep their buttocks on the bench the entire time and keep their feet rooted to the floor? If they have their feet up on the bench, do they keep the lower body stable during the press through abdominal bracing and lower body co-contraction?

Step 7 – Overhead Press

            This movement assessment should be performed with caution, as the “high five” and overhead positions place the shoulder into a less stable position and increases the risk of acute injury if proper exercise technique is not maintained across all sets and reps. Clients with shoulder mobility issues should be instructed to only press to a comfortable height. They should not “reach” or “force” additional overhead ROM if they encounter pain or restriction. If your client has shoulder restrictions from their healthcare provider, strictly adhere to these even if that means you skip overhead press testing and training. There are methods to train the shoulder muscles without overhead press that will be safer for clients with shoulder pathology.

You may perform this assessment with the client’s humerus in full horizontal adduction (arm straight in front of the body), or at varying degrees of horizontal abduction. Some clients should not and will not press with their arms horizontally abducted to 80 degrees or greater. This is acceptable as pressing within lesser ranges of horizontal abduction will still result in global gains in performance and injury prevention.

The client does not need to reach 180 degrees of overhead shoulder flexion (arm straight up) for the press to be complete and effective. Some clients will only press to 80-90 degrees of shoulder flexion due to restrictions or pathology, and this is perfectly acceptable. Help the client find the most comfortable and stable position for them to press in and if you are unable to find this safe and comfortable range, skip the overhead testing entirely.

Instruct the client how to perform a seated dumbbell overhead press, beginning with the arms at zero degrees of horizontal abduction. This is the safest and strongest position for most clients to press in, including those with minor shoulder pathology who have been cleared for limited shoulder exercise by their physical therapist. If the client can perform the press in this position, you do not need to increase horizontal abduction for testing and training purposes.

• Observe the start of the movement: does the client begin with the elbow fully flexed with the load held in front of the body?
• Observe the spine: does the client start the press with spinal extension at any point in the spine? Do they keep their torso braced appropriately?
• Observe the head: does the position remain neutral, or do they flex or extend their neck during the movement?
• Observe the humerus: as the shoulder flexes, the distal end of the humerus (elbow) should translate superiorly (upwards) in a straight line with respect to the body.
• Observe if there is any internal or external humeral rotation during the press in both the concentric and eccentric phases (there may be some internal rotation at the top of the press, but it should be very slight).
• Observe the trapezius: does the client maintain shoulder stability at the top of the press, or do they “reach” or “shrug” at the top of the press?
• Observe the shoulder blades: do they upwardly rotate and protract together as the client presses up? Do they rotate downward and retract even as the client lowers the weight?

Step 8 – Walking Under Load

            Loaded carries are perhaps one of the most effective training modes for building bone density and strength, spinal resiliency, and improving balance and fall risks in nearly all clients. They can be performed both bilaterally and unilaterally, with a preferred 1:2 ratio of said variations as this reflects ADLs more closely.

            Instruct the client in a bilateral carry first. You will need to use sufficient loading (at least 30% of the client’s bodyweight) for there to be enough stimulus for evaluation and training purposes. The client should walk smoothly with heel-toe gait, no bouncing of the shoulders or hips, and a level head. They should walk a distance of at least 20 feet, turn around in place, and then walk back to the starting point. The turn-in-place tests the client’s resistance to spinal shear forces as the loads are rotated around the central axis of the spine.

• Observe the feet: does the client walk smoothly, or do they drop their feet in a choppy or uncontrolled fashion? Do the feet move straight in front of the body with each step, or does the client exhibit medial deviation (crossover) of the feet or lateral deviation of the feet (wider, “waddle” gait).
• Observe the hips: does the client move smoothly or is there noticeable weight shifting that favors one side over the other? Does the client walk with a neutral pelvis or in anterior or posterior pelvic tilt?
• Observe the upper back and shoulders: is the client generating stability by tensing the lats and upper back? Or are they relaxed without shoulder tension?
• Observe the arms and hands: does the weight remain in the same relative place during the carry, or does it swing in the sagittal plane, rotate in the transverse plane, or translate in the frontal plane?
• Observe the spine: does the client maintain natural lumbar curvature and a straight spine, or do they deviate laterally, frontally, or posteriorly?
• Observe the head position: is the head erect and neutral, or does the client let the chin drop or tilt their head upwards?
• Observe the turn-in-place: does the client maintain control over the weights? Do they exhibit spinal rotation or lateral flexion as they turn?
  
  For unilateral carry evaluation:
  
  
• Observe all the same points as with bilateral carries, with special attention to lateral flexion and axial rotation of the spine.

Step 9 – Cardiorespiratory Evaluation

            This assessment can be conducted a variety of ways. One method I use often is a modified Rockport Walking Test conducted on a treadmill. The instructions for the Rockport Walking Test are easily found in Personal Trainer textbooks and on the web, and you should already be familiar with this test.

This test will permit you to estimate the client’s VO2 max using prediction equations and use that for cardiorespiratory exercise (CRE) prescription. The treadmill should be set at an incline of 2% to remove the mechanical advantage the treadmill confers to the client and most closely simulate walking on level ground.

            Another reliable method of CRE testing is the YMCA step test. This test is performed using a 12” step (you may reduce the step height if unsafe for the client, but this will influence the test results somewhat).

The client must step at a rate of 96 beats per minute, with a 4-count step cycle. Beat 1 is the first foot on the step; beat 2 is the second foot on the step; beat 3 is the first foot down, and beat 4 is the second foot down, which completes 1 repetition. The test lasts 3 minutes, and the score is the client’s heart rate taken immediately after the test is completed while sitting down with feet flat on the floor. The lower the heart rate, the better the score. The scoring table is available online.

            There are many other validated ways to measure CRE performance, but these two are the simplest and easiest to implement for most clients.

Summary

            The order that these assessments are listed in is the order you should complete them in. Saving the CRE assessment until the end builds in cooldown time for the client, and they should perform light stretching afterwards as indicated under your direction once they are done with all testing.

            Safety of the client is always the number one priority. If anything occurs during testing that could put the client at risk, STOP, and evaluate the risk and determine if continuing testing is safe or if it needs to be rescheduled.

            The method I have outlined here is not the only high-quality and reliable way to screen and assess client’s movement skills. The screens you use will be dictated by the client’s health status and any mobility restrictions they have. Keep your screening simple and to the point, reflecting ADLs and identifying injury risk points.

            If the client you are screening has joint pathology, please reach out to their physical therapist or other healthcare provider to obtain guidelines and restrictions for their patient. It is your responsibility to do this prior to any exercise training services being rendered. It is also beneficial to build positive, 2-way relationships with healthcare providers since this will build trust with them as well as provide you with a potential referral network.

            If you have questions regarding this article, please reach out to me and I will be happy to answer your questions.

Move Well, Live Well!

-Josh