Tuesday, April 28, 2009

Turkish Get Up a Good Cheap Movement Screen? Then whither the FMS?

Last week i wrote about questions that have come up around the RKC/gray cook way of teaching the turkish get up, in particular the high hip bridge. In Gray Cook's thoughts on this, motivated by Anthony Diluglio's challenge as to its efficacy and safety, Cook claims that the "speed bumped" TGU is a great diagnostic tool. This week, i'd like to come back to the Turkish Get Up (the TGU) as a diagnostic move, and at least set some terms to open up the question diagnostic of what, beyond itself? And if what, why need any other movement screen, like say the FMS? In a sense, this post is an experiment in testing "logical conclusions" of an idea.

My rationale for this query is that folks, including athletic groups, with whom i'm working, are asking about comparisons among screens, and wanting to get the most bang for their buck. If the TGU is a great diagnostic, what more is needed?

see UPDATE I below; Update II below

Indeed, i've suggested to Brett Jones myself, based on the case study i did for my ck-fms certification, that the TGU could replace the FMS as a screen - what if anything does it miss from the screen? Haven't quite had a final answer on that one, and didn't push it - more of a witty observation - but we're gonna come back to that question here.

One of the things the kalos-sthenos DVD on the TGU by Cook, Jones and manual by Cheng gives to practitioners/coaches is to say if you see problems with any of these positions in the TGU, here's the corrective strategies to fix these issues and enable better mobility and stability not just in the TGU, but beyond. From the manual:

For the fitness and medical professional, the TGU serves as a fundamental movement primer, a corrective exercise, a conditioning system, and a movement screen. It is a useful tool to both detect and address movement pattern asymmetries and weaknesses.

Doesn't that sound excellent (aside from the split infinitive)? Even cheaper than the FMS, the turkish getup DVD set lets a coach see where performance asymmetries may be in their athlete, and then fixing these addresses those issues. The assertion is, address these issues in this move, and you have great carry over to other moves. Again, from the manual:
Clinically, there's no shortage of patients who've made major breakthroughs with challenging rotator cuff problems thanks to the Turkish Get Up)...Any athlete who serves a tennis ball, spikes a volleyball, swings a golf club, or pitches a barseball will certainly appreciate the kind of coordinated strength that the TGU develops.
I would love to see some work that showed those claims can be directly attributed to work with the TGU, but it sounds reasonable, so let's go with it for a moment, and look at at least Cook's rationale for the functional movement screen: that just by reducing asymmetries in the screen (left side in something better than the right or just different than the right) reduces injury. At least in the NFL and for firefighters. Other sports, some researchers have suggested, not so much - so far - at least with the data that's been collected, showing no statistical improvement.

Quince to Granny Smith or Apples to Oranges: FMS and TGU
But if we set the mixed research results aside for a moment, and just agree with the assertion that a movement screen is a good thing, then let's take this back to the KS TGU as screen. Is the TGU unique its ability to act as a screen compared with any other isolateral moves? Perhaps not (consider the 7 moves of the FMS including the squat, push up and lunge variant), but it's hard to think off the top of my head what other movement focuses on one side of the body at a time and moves from supine to standing, upper body focus to lower body focus.

And it seems it's that particularity that's being claimed for the TGU: while the FMS isolates in its moves particular issues, one at a time, the TGU seems to get most of 'em in each part of one excercise, hence my query as to what's in the FMS that isn't caught in the TGU - or is there a vice versa?

Seven tests in the FMS; seven moves in the TGU. Do they map at all? Anything left out? How is the FMS sufficient or insufficient in comparison to the TGU, or vice versa?

Here's a quick check list from the FMS sheet on the FMS site paralleled with the TGU bits.
Test one: squat
The ability to perform the deep squat requires appropriate pelvic rhythm, closed-kinetic chain dorsifl exion of the ankles, flexion of the knees and hips and extension of the thoracic spine, as well as fl exion and abduction of the shoulders.
Ok, what part of the TGU maps to flexion of the knees and hips and extension of the thoracic spine and flexion and abduction of the shoulders? Well one side at a time, in the upper body part of the TGU, thoracic spine mobility and shoulder flexion and abduction are present. Indeed a corrective drill in the TGU is to do "thoracic glides" when up on the elbow and the weight is overhead. The ankles may well be tested when going to stand up or come back down.

Test two: hurdle step
Performing the hurdle step test requires stanceleg stability of the ankle, knee and hip as well as maximal closed-kinetic chain extension of the hip. The hurdle step also requires step-leg open-kinetic chain dorsiflexion of the ankle and flexion of the knee and hip. In addition, the subject must also display adequate balance because the test imposes a need for dynamic stability.
Where in the TGU is any part of the above checked? Well the high hip bridge certainly tests a kind of stance leg hip extension; the ability to keep the knee up and in good position could come back to dorsiflexion of the ankle and flexion of the knee and hip. ok. and balance, well that's throughout the movement, tho not as taxed as in the hurdle step.

Test Three: inline lunge
This test assesses torso, shoulder, hip and ankle mobility and stability, quadriceps flexibility and knee stability. The ability to perform the in-line lunge test requires stance-leg stability of the ankle, knee and hip as well as apparent closed kineticchain hip abduction. The in-line lunge also requires step-leg mobility of the hip, ankle dorsifl exion and rectus femoris flexibility. The subject must also display adequate stability due to the rotational stress imposed.
Of any of the tests, perhaps the closest match is in the inline lunge with the genuflecting part of the TGU. It's not inline, but you do have to get up and down gracefully with a weight overhead while laterally moving the trunk up from flexion back to neutral with the arm overhead. Lots of stability stuff. dorsiflexion, too.

Test Four - Shoulder Mobility
The ability to perform the shoulder mobility test requires shoulder mobility in a combination of motions including abduction/external rotation, flexion/extension and adduction/internal rotation. It also requires scapular and thoracic spine mobility.
It seems that the entire TGU is a test of shoulder mobility. How one might assess asymmetries is interesting to watch the position of the bell relative to the shoulder throughout the move.

Test Five: active straight leg raise
The ability to perform the active straight-leg raise test requires functional hamstring flexibility, which is the flexibility that is available during training and competition. This is different from passive flexibility, which is more commonly assessed. The subject is also required to demonstrate adequate hip mobility of the opposite leg as well as lower abdominal stability.
Hip mobility is shown again in keeping the knee from valgus collapse on the way up, and in the high hip bridge, as well as in the uprightness of posture while moving from high hip bridge up to upright kneeling, ready to step up. It's also shown in the ability to keep the leg out stiff without it having to leverage up (leave the ground) when getting up.

Test six: Trunk Stability Push Up
The ability to perform the trunk stability push-up requires symmetric trunk stability in the sagittal plane during a symmetric upper extremity movement.

Well i dunno what to say about this one. It seems the closest thing to the push up/ trunk stability is again the high hip bridge - that's the only part of the move as far as i can tell where the upper and lower parts of the body are working together - similar to a yoga table - with one arm and one leg for balance. Likewise getting up on the elbow with a bell overhead and keepint that post leg out straight and not coming up from the ground - that's pretty core activated, too.

Test Seven: Rotary Stability (elbow knee touch over a board, same side elbow to same side knee)
The ability to perform the rotary stability test requires asymmetric trunk stability in both sagittal and transverse planes during asymmetric upper and lower extremity movement.
This test too is a bit of a question mark since the tgu is isolateral but diagonal throughout. But again, if that high hip bridge is working its magic, shouldn't folks with a strong high hip bridge on both sides test well here?

Now this is just a first pass comparison, and the mappings mayn't be as good as they could be, so i'd be pleased to hear about refining/correcting what's proposed.

FMS /TGU close but no cigar? How close? How Far?

After the above excercise comes the obvious question: what are we missing in the TGU: Gray Cook to say whether the comparisons between TGU and FMS are sufficiently strong to be powerful? Consider what's missing with the TGU as given in the DVD: a scoring system on both sides of the move. That one might argue is a critical part to the bullet proofness of the FMS. THere are strict criteria for scoring how well a move is performed on both right and left. it's 0,1,2 or 3 and each of these have meanings. Each of the FMS neatly unpacks each set of issues. But so what? the TGU gets just about all of them and possibly some that the FMS doesn't get.

Eg, where is the psoas/glutes connection of the high hip bridge caught in the FMS? is that better amplified in the TGU than the push up since the push up is all about trunk stabilizers?

TGU cheap FMS?
So we come back to the assertion of the TGU as a cheap screen: we've seen - by my very rough calculations - that the TGU does seem to map pretty well to what's exposed in the FMS. So the next part of the screen equation would be: if you can apply the checks at each phase of the TGU, and correct them, your athlete will be in a better place for other activities, as asserted in the TGU manual - not just for doing a better TGU.

How do we test that?
What's the test for the benefit of being able to do a hard style TGU? where's the check to see if there's been good transference as claimed? It makes sense that there should be, but how do i evaluate this, and attribute it back to the TGU work rather than anything else?

While the KS dvd focuses on improving the TGU, i'd be curious to see in a DVD someone with crap shoulder range of motion who throws a football or poor hip mobility who likes to golf, see how they test on the TGU (if those issues show up there), do TGU work and see how their swing mobility improves in the golf stroke for instance.

Why is that testing of transference important? well, we're spending a lot of energy talking about the benefit of this new "speed bumped" TGU *as* a diagnostic, and it looks like there's a pretty good case to be made for it against the FMS when *used* as a diagnostic rather than as an execercise - and that should mean it works as a diagnostic for other issues that if fixed in this TGU context will benefit other contexts. How do we prove the correlation?

So, while working on fixing the TGU looks great, and why not? there seem to be two questions:
  1. If the TGU is a super diagnostic, why bother with the FMS? What's missing in the TGU-as-screen that is not in the FMS? Beyond the scoring system (couldn't that be adapted), what are we missing?
  2. Do the TGU fixes have transference?
These are questions that clients if not practitioners will be asking. At the university where i'm beginning a pilot program for team screenings, the sports groups are evaluating various movement screens (the FMS ain't the only show in town), and these are the kinds of value-for-money queries they have. Likewise RKC's and other practitioners who get that there's value in doing movement assessment may see the TGU as a more immediate value proposition than say the investment in the FMS: no special equipment, and it's a move already in the repertoire. No secrets of dvd's required, the reasoning might be, since the corrections are in the manual and across the two dvd's.

Coda: Teaching the TGU - correct move or corrective movement?
An intriguing consequence of developing the TGU-as-diagnostic is that the TGU is still a core move of the RKC Level 1 certification. It will be interesting to see how movement assessment moves into the RKC rather than simply teaching correct posture in a move. Which makes me come back to diluglio's critique of what he was seeing in his classes of people perhaps *attempting* to get the high hip bridge and not getting it - what diluglio models of what he's seeing is not a high hip bridge. The glutes and psoas do not seem all planked up and engaged.

So what's going on? Were there a bunch of similarly weak hip bridges in front of Anthony? or something else?

And if there are weaknesses in client performance - assuming folks doing this form went to an RKC (as the book/dvd wasn't yet out) where will RKC's get the training they need to deliver the corrective strategies to support rehabbing this move? Right now, i understand that the ck-fms will be going through the corrective strategies this year from the KS TGU manual. It will also be interesting to see how this work influences the teaching of TGU teaching, as it were, in the RKC.

And finally: the non-jock
If everyone who moves is an "athlete" does the TGU help all "athletes"? It seems we're talking about totally able bodied folks here who are interested enough to do a TGU and who can perform a TGU.

I work with clients who have mobility/stability issues, and who cannot complete a successful bodyweight TGU. Does this mean that their mobility cannot be assessed until their strength improves? Isn't that rather self-defeating? how address that building up of potential dysfunction ontop of strength if movement isn't assessed from the outset? It seems the TGU or the FMS become more niche instruments than initially anticipated. I think we forget sometimes how fortunate we are in our strength skills.

In this article i've attempted to ask the question what really is the TGU as diagnostic diagnosing?
  • If it's a "movement screen" and "corrective exercise" and "diagnostic" - what's it actually showing?
  • If it's hitting all the same bells and whistles as the FMS - or 90% of them - whither the FMS beyond a score card?
  • And if the FMS is far more clear than the TGU of what then can be read from the TGU that is transferable to other activities?
  • And what about clients for whom a deep squat or tgu is still the impossible dream?
Lest anyone think i'm poking a finger in the eye of the TGU as diagnostic again, let me contextualize - i'm one of about a dozen people out of 60 who have completed their CK-FMS certification, which means i'm both a cert'd FMS specialist and a CK-FMS certed specialist. I also hold an RKC cert and look forward to assisting at this year's Denmark RKC cert where Mark Cheng Team Lead will be the TGU source, and i'll be happy to screen anyone there gratis who asks, with the head instructor's permission. I also as said used the TGU as part of my corrective strategies in the case study i did for my ck-fms and have said why the FMS if you have the TGU? So, that should look like someone who's gotten pretty deep into the Program.

But as with any curriculum, its practitioners advance the field by asking (hopefully good) questions - before their clients/students do - and if the answers are wanting, well that's something to address. Likewise knowledge of multiple techniques helps enhance the view.

SO as you can see i don't entirely have complete answers to the questions i've raised, but hope there'll be some good informed discussion. This is less a complete statement than a working paper.


Update 1,
i asked Brett Jones in particular if he would cogitate on this comparison and look at a reply. He posted today as well on his blog with a pretty detailed comparison. Instead of going from the FMS to the TGU, he's gone from the TGU to the FMS
I'm looking forward to stepping through the response. Thanks Brett. In particular his summary comparison between the TGU and the FMS:

  • FMS tests stability (called coordination by some) in symmetrical stance, asymmetrical stance and single leg stance. Get-up only gets asymmetrical (and that doesn't ask for the same crossing of midline).
  • FMS tests mobility of the hip, knee, ankle and shoulder - in multiple positions - the Get-up does this to an extent but not the same and not in the symmetrical and single leg stances.
  • FMS tests reflexive core stabilization in the Trunk Stability Push-up - the Get-up doen't really get this. the Punch to Elbow is more rotary in nature but does have some reflexive stabilization in it but as I said it is more rotary in nature.
  • FMS tests Shoulder Mobility with a specific reach incorporating Thoracic extension, Shoulder abduction/external rotation and flexion and Shoulder addcution/internal rotation and extension. While the Get-up assesses shoulder mobility and thoracic mobility it misses some of the specific positions of the SM test but does incorporate moving the body around a stabile shoulder - unique to the Get-up.
  • FMS tests split you in to Right and Left halves in 5 of the tests looking for asymmetry - The Get-up does this to an extent and within the moves of the Get-up and the tie-ins as mentioned.
  • Any exercise that is performed on the right and then left side can be a chance for evaluation of symmetry.
  • FMS tests (once all 7 are performed) allow you to quickly identify the Weak Link and provides corrections for those weak link (s). The Get-up can find a weak link but it may just be specific to the Get-up and not as targeted as the FMS identified weak link.

Update II - Cpt Brett.

Have to thank Brett for taking the time to go over the FMS/TGU variants the way he has. Indeed, he's said in fact that he will also check out my question about what gets missed that the FMS would catch *that is meaningful* that the TGU misses.

Right now, we can certainly agree that the FMS has more going on in it. See Brett's careful analysis above, and i'd check out his blog post too.

But it seems that we're still *hypothesizing* that of course because the FMS tests more stuff more, it's better, more precise. More precise right now yes, but maybe less is also more, or maybe it's not? I'm still wondering what that "precision" from the FMS gets most of us. Is it an 80/20 thing?

When i did Z health R phase certification (review), i remember Mike T Nelson saying that the learning in the R phase cert would help *solve* the issues of 80% of the people i'd see. That's pretty durn good for a foundational cert. Is the TGU a kind of similar screen? An 80% (or more) of the FMS?

Brett talks passionately about being able to draw on the right tool for the client. His own background in Z, FMS, his uni education, all testify to how he's built a robust and rich tool box.

I guess i'm thinking - as someone whose invested in the FMS too - that i'd like to be able to say with some certainty, when is the FMS a *better* tool than the TGU? For which client?

Looking forward to more FMS/TGU comparison reports.

related posts: zhealth - about ||zhealth assessment


Max Shank said...

Nicely done, mc.

dr. m.c. said...

Thank you, Max, and thanks for stopping by to say so.

best in your practice,


Unknown said...

I enjoyed the article.

One thing I notice about turkish getups is how they change from your1'st-15'th to say your 30'th or 50'th one in a workout.
Exhustion from more than 10 or 15might also help identify alot about a persons strength and flexibility. Where people start to cheat/ or make adaptations becomes interesting.


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