Using disablement models and clinical outcomes assessment to enable evidence-based athletic training practice, part I: disablement models

The Effects of Injury Type on Health-Related Quality of Life in Youth Athletes: A Cross-Sectional Analysis

OBJECTIVE

The relationship between health-related quality of life (HRQoL) and injury type has not been analyzed for young athletes. We hypothesized that there would be no difference in HRQoL between injured athletes, injured nonathletes, and normative data for healthy youth (NDHY) or among athletes with acute, overuse, or concussion injuries.

DESIGN

Cross-sectional clinical cohort.

SETTING

Primary care sports medicine clinics at 3 academic institutions.

PARTICIPANTS

Patients aged 8 to 18 years presenting with injury.

INDEPENDENT VARIABLES

Injury type and athletic participation.

MAIN OUTCOME MEASURES

Health-related quality of life measured 1 month after injury through the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric-25 v2.0 assessed pain interference, peer relationships, depression, fatigue, anxiety, and mobility. One-way analysis of variance was performed with P values of <0.05 considered significant. Concussion Learning Assessment and School Survey (CLASS) evaluated academic performance.

RESULTS

Three hundred fifty-seven patients (36% male), with average age of 14.2 years, completed HRQoL and CLASS surveys following injury. There were 196 overuse injuries (55%), 119 acute injuries (33%), and 42 concussions (12%). Ninety-four percent were athletes. Six percent were nonathletes; 90.5% of concussed patients reported grades worsening. Concussed athletes reported more fatigue (P = 0.008) compared with other injury types but no worse than NDHY. Athletes with overuse injuries had lower mobility (P = 0.005) than other injury types and NDHY. Patients with lower HRQoL were female, older age, or required surgery. No other domains had significant differences by injury type nor did HRQoL differ between the athletes, nonathletes, and NDHY.

CONCLUSIONS

With the exception of injuries requiring surgery, HRQoL of injured young athletes was similar to NDHY in most domains.

Poor Mental Health Indicators in Individuals With Patellofemoral Pain

CONTEXT

Patellofemoral pain (PFP) is a common source of knee pain in active individuals, accounting for a large number of knee injuries examined in sports medicine clinics. As a chronic condition, PFP can affect mental health. However, this effect has not yet been studied in individuals with PFP.

OBJECTIVE

To determine how subjective physical and mental health measures in individuals with PFP differed from those measures in pain-free individuals.

DESIGN

Case-control study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

Volunteers for the study were 30 people with PFP (19 women, 11 men; age = 20.23 ± 3.32 years, height = 166.69 ± 6.41 cm, mass = 69.55 ± 13.15 kg) and 30 matched pain-free individuals (19 women, 11 men; age = 20.33 ± 3.37 years, height = 169.31 ± 9.30 cm, mass = 64.02 ± 11.00 kg).

MAIN OUTCOME MEASURE(S)

Current and worst pain levels in the past 24 hours were determined using a visual analog scale (VAS). The Anterior Knee Pain Scale, Fear Avoidance Belief Questionnaire, and Lower Extremity Functional Scale were administered. Physical and mental health measures were obtained using a modified 12-item Short Form Health Survey. Scores for 2 subscales on the modified Short Form-12 were weighted and calculated: physical component and mental component.Independent t tests were calculated to compare variables between groups. Coefficient correlations were used to measure the associations between the variables.

RESULTS

Individuals with PFP reported lower levels of physical (pain free: 56.13 ± 1.63, PFP: 50.54 ± 7.10, P < .001) and mental (pain-free: 53.32 ± 4.71, PFP: 48.64 ± 10.53, P = .03) health. In the PFP group, we found moderate negative correlations between the VAS score for current pain and mental health (r = -0.52, P < .01) and between the VAS score for worst pain in the past 24 hours and mental health (r = -0.46, P = .01) and between activity limitations in individuals with PFP and fear avoidance beliefs (r = -0.61, P < .01).

CONCLUSIONS

Our results should encourage clinicians, especially musculoskeletal rehabilitation professionals, to acknowledge the importance of a whole-person approach when treating or planning rehabilitation programs for individuals with PFP.

A Model for Applying Situational Awareness Theory to the Return to Sport Continuum

Background

Despite developing and implementing return to sport guidelines, high rates of re-injury remain. The return to sport continuum is a three-phase, criterion-based progression based on physical and psychological factors used to guide the sports medicine team in return to sport decision making. Situational awareness (SA) pertains to an athlete's knowledge of the dynamic environment (i.e., their ability to perceive the components in the environment, comprehend the meaning of the perceived information, and predict future actions based on that comprehension). SA can be applied on a cognitive continuum that encompasses three levels, each stage becoming more challenging with additional time constraints and increased uncertainty. Integrating the cognitive continuum with the return to sport continuum may optimize the return to sport process and enhance the athletes' preparedness for competition by incorporating cognitive challenges aligned with live competition. The purpose of this clinical commentary is to describe a return to sport model that integrates SA theory on the cognitive continuum with additional consideration for surrounding contextual factors.

Level of Evidence

5©The Author(s).

Patient-Reported Outcomes at Return to Sport After Lateral Ankle Sprain Injuries: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

Limited evidence exists regarding the assessment of single-item patient-reported outcomes when patients are medically cleared to return to sport after a lateral ankle sprain (LAS) injury.

OBJECTIVE

To evaluate self-reports of improvement in health status, pain, function, and disability at return to sport after an LAS.

DESIGN

Descriptive study.

SETTING

Sixty-nine athletic training facilities across 24 states.

PATIENTS OR OTHER PARTICIPANTS

A total of 637 patients (males = 53.2%) who were diagnosed with an LAS, restricted from sport after injury, and subsequently medically cleared to return to sport within 60 days were included.

MAIN OUTCOME MEASURE(S)

Descriptive statistics were used to summarize scores for health status (Global Rating of Change), pain (Numeric Pain Rating Scale), function (Global Rating of Function), and disability (Global Rating of Disability). Mann-Whitney U tests were used to compare score differences between sexes. A Kaplan-Meier analysis was performed to provide a visual depiction of sex differences in the time to return to sport.

RESULTS

Most patients sustained an LAS injury while participating in basketball, football, or soccer and were cleared to return to sport 8 days after injury. More than two-thirds of patients reported a meaningful improvement in health status between the time of injury and return to sport. However, many noted deficits related to pain (65.1%), function (86.2%), or disability (35.8%) at return to sport. No differences were seen between males and females for pain (P = .90), function (P = .68), change in health status (P = .45), or disability (P = .21) at return to sport, although males returned to sport slightly sooner than females (P = .025).

CONCLUSIONS

Despite self-perceived improvements in health status since the time of injury, patients typically returned to sport with deficits in pain, function, and disability after an LAS. Patients may be returning to unrestricted sport participation before they feel their bodies have fully recovered from the injury.

The Knowledge and Use of the International Classification of Functioning, Disability and Health (ICF) Framework in Athletic Training

In 2015, the Strategic Alliance adopted the International Classification of Functioning, Disability, and Health (ICF) as the disablement model framework for delivery of and communication about patient care in athletic training. The purpose of this study was to examine athletic trainers' familiarity, knowledge, application, and implementation of the ICF framework. We used a cross-sectional online survey with 185 athletic trainers (age = 35 ± 9 y), which included 32 items focused on familiarity, knowledge, application, and implementation of the ICF framework. Most participants (n = 96, 51.9%) reported never learning about the ICF framework. During the knowledge assessment, participants scored 4.3 ± 2.7 out of 8, which is equivalent to 53.7%. For the sorting assessment, participants scored 10.9 ± 3.9 out of 18, which is equivalent to 60.5%. On the implementation matrix, the most frequently reported ICF tasks elicited by the athletic trainers included neuromusculoskeletal and movement, structure related to movement, and mobility. The most common 'never elicited' ICF tasks included voice and speech, sexual orientation, and structures related to genitourinary and reproductive system. Deficits related to the ICF framework exist. Athletic trainers reported low implementation across all ICF categories. The decision to not elicit information on these areas of health may reduce the ability to provide patient-centered healthcare.

Use of Rehabilitation Therapy in Palliative Care Patients

Palliative care is a unique area of veterinary medicine, where primary goals include maintaining quality of life, as opposed to treating with a curative intent. Using the disablement model and client partnership allows for the development of a function-targeted treatment plan individualized to patient and family needs. Rehabilitation modalities, especially when combined with adaptive pain management, are well-suited to palliative care because they can greatly enhance a patient's ability to achieve improved function and quality of life. These areas join in a concept called palliative rehabilitation which combines the unique needs of these patients and the tools accessible to the rehabilitation practitioner.

Cross-Cultural Adaptation and Validation of the Persian Version of the Functional Arm Scale for Throwers

BACKGROUND

The Functional Arm Scale for Throwers (FAST) is a reliable and valid region-specific tool designed to evaluate health-related quality of life in throwing athletes with upper-extremity injuries. The purpose of this study was to adapt, translate, and evaluate the psychometric properties of the Persian version of the Functional Arm Scale (FAST-Persian) for use in throwing athletes.

MATERIALS AND METHODS

The study was conducted based on 5 steps of cross-cultural adaptation including forward translation, synthesis, backward translation, expert committee review, and pretesting. The final Persian questionnaire, along with Persian versions of Disabilities of the Arm, Shoulder, and Hand and Kerlan-Jobe Orthopedic Clinic questionnaires, was completed by 177 throwing athletes for validity analysis. After 7 to 14 days, the FAST-Persian was reanswered by 80 throwers, who had no changes in this time interval. Internal consistency and test retest reliability were used to evaluate reliability of the questionnaire. Standard error of measurement and smallest detectable changes were also calculated. Construct validity was determined by correlational analysis with Disabilities of the Arm, Shoulder, and Hand and Kerlan-Jobe Orthopedic Clinic questionnaires. Dimensionality was evaluated with factor analysis.

RESULT

Cronbachs alpha was .99, and the interclass correlation coefficient levels for total score and 5 subscales of the FAST-Persian ranged between .98 and .99. The standard error of measurement and smallest detectable changes were 3.17 and 8.80, respectively. The FAST-Persian had a high correlation with Disabilities of the Arm, Shoulder, and Hand (r = .98, P < .0001) and Kerlan-Jobe Orthopedic Clinic (r = .98, P < .0001) scores. Factor analysis revealed one factor with a total variance of 75.23%.

CONCLUSION

The FAST-Persian is a reliable and valid measurement tool that can be used to evaluate health-related quality of life in overhead athletes and throwers.

Athletic Trainer's Varying Levels of Awareness and Use of Disablement Model Frameworks: A Qualitative Study

In healthcare, disablement model frameworks aim to improve the delivery of patient-centered care through the recognition of patient factors beyond impairments, restrictions, and limitations, which include personal, environmental, and societal factors. Such benefits translate directly to athletic healthcare providing a mechanism for athletic trainers (ATs), as well as other healthcare professionals, to ensure that all aspects of the patient are managed prior to returning to work or sport. The purpose of this study was to investigate ATs recognition and use of disablement frameworks in current clinical practice. We used criterion sampling to identify ATs who were currently practicing from a random sample of ATs that participated in a related cross-sectional survey. A total of 13 participants engaged in an online, audio-only, semi-structured interview that was audio-recorded and transcribed verbatim. A consensual qualitative research (CQR) approach was used to analyze the data. A coding team of three individuals used a multi-phase process to construct a consensus codebook that identified common domains and categories among the participants' responses. Four domains emerged regarding ATs' experiences and recognition of disablement model frameworks. The first three domains were related to the application of disablement model frameworks: (1) patient-centered care, (2) limitations and impairments, and (3) environment and support. Participants described varying degrees of competence and consciousness regarding these domains. The fourth domain related to participants' exposure to disablement model frameworks through formal or informal experiences. Findings suggest that ATs largely demonstrate unconscious incompetence regarding the use of disablement frameworks in clinical practice.

Participant-Level Analysis of the Effects of Interventions on Patient-Reported Outcomes in Patients With Chronic Ankle Instability

CONTEXT

Intervention studies for chronic ankle instability (CAI) often focus on improving physical impairments of the ankle complex. However, using an impairments-focused approach may miss psychological factors that may mediate function and recovery. Patient-reported outcome (PRO) measures can be used to assess several dimensions of the health-related quality of life (HRQoL) and deliver enhanced patient-centered care. Therefore, the purpose of this investigation was to evaluate group-level improvements in HRQoL and treatment response rates following various interventions in patients with CAI.

DESIGN

Cross-sectional.

METHODS

Data from 7 previous studies were pooled by the chronic ankle instability outcomes network for participant-level analysis, resulting in 136 patients with CAI. Several interventions were assessed including balance training, gait biofeedback, joint mobilizations, stretching, and strengthening, with treatment volume ranging from 1 to 4 weeks. Outcome measures were PROs that assessed ankle-specific function (Foot and Ankle Ability Measure), injury-related fear (Tampa Scale of Kinesiophobia and Fear Avoidance Belief Questionnaire), and global well-being (Disablement in the Physically Active); the PROs assessed varied between studies. Preintervention to postintervention changes were evaluated using separate Wilcoxon signed-rank tests and effect sizes, and a responder analysis was conducted for each PRO.

RESULTS

Significant, moderate to large improvements were observed in PROs that assessed ankle-specific function, injury-related fear, and global well-being following intervention (P < .001). Responder rates ranged from 39.0% to 53.3%, 12.8% to 51.4%, and 37.8% for ankle specific function, injury-related fear, and global well-being, respectively.

CONCLUSIONS

Various interventions can lead to positive improvements in HRQoL in patients with CAI. Treatment response rates at improving HRQoL are similar to response rates at improving impairments such as balance, further reinforcing the need for individualized treatment approaches when treating a patient with CAI.

Patient-reported outcome measures as an outcome variable in sports medicine research

Injury prevention and rehabilitation research often address variables that would be considered clinician-oriented outcomes, such as strength, range of motion, laxity, and return-to-sport. While clinician-oriented variables are helpful in describing the physiological recovery from injury, they neglect the patient perspective and aspects of patient-centered care. Variables that capture patient perspective are essential when considering the impact of injury and recovery on the lives of patients. The inclusion of patient-reported outcome measures (PROMs) as dependent variables in sports medicine research, including injury prevention and rehabilitation research, provides a unique perspective regarding the patient's perception of their health status, the effectiveness of treatments, and other information that the patient deems important to their care. Over the last 20 years, there has been a significant increase in the use of PROMs in sports medicine research. The growing body of work gives opportunity to reflect on what has been done and to provide some ideas of how to strengthen the evidence moving forward. This mini-review will discuss ideas for the inclusion of PROMs in sports medicine research, with a focus on critical factors, gaps, and future directions in this area of research. Important elements of research with PROMs, including instrument selection, administration, and interpretation, will be discussed and areas for improvement, consideration, and standardization will be provided.

Cancer Prehabilitation in Practice: the Current Evidence

PURPOSE OF REVIEW

This article serves to describe recent controversies in cancer prehabilitation including efficacy, dose, cost effectiveness, stakeholder input, and international implementation.

RECENT FINDINGS

Appropriate frequency, type, and timing have yet to be determined, but high intensity exercise is recommended. Costs are favorable when modeled and information on costs of real-world application are forthcoming. Patients are interested in and willing to attend cancer prehabilitation. Cancer prehabilitation research is spreading throughout the world. Cancer prehabilitation includes assessment of a newly diagnosed cancer patient's baseline fitness and targeted interventions to improve their health before surgery, chemotherapy, or radiation. Cancer prehabilitation improves fitness as measured preoperatively and improves outcomes postoperatively.

Interpreting patient-rated outcome measures in adolescent patients following concussion

OBJECTIVE

To estimate scale scores for patient-reported outcome (PRO) measures that classify patients as improved or unimproved at days 3 and 10 post-concussion.

METHODS

Data from 187 adolescent patients who sustained a concussion (150 males, 32 females, 5 not reported) were analyzed. Patients completed the Pediatric Quality of Life Inventory (PedsQL), PedsQL Multidimensional Fatigue Scale (MFS), Headache Impact Test (HIT-6), and Global Rating of Change (GROC) on days 3 and 10 post-concussion. Dependent variables: PedsQL total score, 3 MFS subscale scores [general (MFS-GF), sleep (MFS-SLF), cognitive (MFS-CF) fatigue], and HIT-6 total score. Higher scores on PedsQL and MFS indicate better health; lower scores on HIT-6 indicate less impact on headache-related health. GROC ascertained patient-perceived magnitude of change in health status since concussion. Receiver Operating Characteristic Curve analyses estimated PRO cut-point scores that classified patients as improved or unimproved.

RESULTS

Day 3 PRO cut-points: PedsQL total = 90; MFS-GF = 73; MSF-CF = 85; MFS-SLF = 81; and HIT-6 total = 54. Day 10 PRO cut-points: PedsQL total = 91; MFS-GF = 85; MFS-CF = 85; MFS-SLF = 90; and HIT-6 total = 51.

CONCLUSIONS

Our results define PedsQL, MFS, and HIT-6 scores as they relate to perceived improvement following concussive injuries. Cut-point scale scores help clinicians interpret concussion PROs and make informed decisions during the management of patients with concussion.

Canine Geriatric Rehabilitation: Considerations and Strategies for Assessment, Functional Scoring, and Follow Up

Geriatric animals account for half of the pet population in the United States with their numbers increasing annually. Furthermore, a significant percentage of veterinary patients with movement limitations could be grossly categorized as geriatric and living within the end stage of their predicted lifespans. Because mobility is correlated to quality of life and time to death in aging dogs, a major goal in optimizing canine geriatric health is to improve functional movement. Within the geriatric population, identifying disabilities that affect daily living and quality of life may be used by the rehabilitation practitioner to provide stronger prognoses, treatment goals, and outcome measures. Examples of such means are described within this review. In human medicine, the concept of “optimal aging”, or “healthy aging”, has emerged in which inevitable detrimental age-related changes can be minimized or avoided at various levels of physical, mental, emotional, and social health. Both environment and genetics may influence aging. Identifying and improving environmental variables we can control remain a key component in optimizing aging. Furthermore, diagnosing and treating age related comorbidities common to older populations allows for improved quality of life and is often directly or indirectly affecting mobility. Obesity, sarcopenia, and a sedentary lifestyle are a trifecta of age-related morbidity common to both people and dogs. Healthy lifestyle choices including good nutrition and targeted exercise play key roles in reducing this morbidity and improving aging. Disablement models act as essential tools for creating more effective physiotherapy plans in an effort to counter dysfunction and disability. Within these models, functional testing represents a standard and validated means of scoring human geriatric function as well as monitoring response to therapy. Because of the great need in dogs, this review aims to provide a reasonable and testable standardized framework for canine functional scoring. We believe a complete assessment of canine geriatric patients should comprise of identifying environmental variables contributing to health status; diagnosing comorbidities related to disease and aging; and characterizing disability with standardized methods. Only through this process can we construct a comprehensive, reasonable, and targeted rehabilitation plan with appropriate follow up aimed at healthy aging.

Disablement in the Physically Active Scale Short Form-8: psychometric evaluation

Background

Patient-centered care and evidence-based practice (EBP) are core competencies for health care professionals. The importance of EBP has led to an increase in research involving clinical outcomes; current recommendations emphasize collecting patient focused measures, thus increasing the need for psychometrically sound patient reported outcome measures (PROMs) of health. Disablement has been identified as a valuable multi-dimensional construct for patient care. The Disablement in the Physically Active Scale Short Form-8 (DPA SF-8) has been proposed as a tool to be used in the physically active population that assesses a physical summary component of health and a quality of life component however, further analysis is necessary to ensure the instrument is psychometrically sound.

Methods

Confirmatory factor analyses (CFAs) were conducted on the DPA SF-8 at each time point to ensure factor structure. Reliability of the scale and internal consistency of the subscales were assessed, and a minimal detectable change (MDC) calculated. Additionally, a minimal clinically important difference (MCID) was also established, and invariance testing across three time points and groups was conducted.

Results

The CFAs at all three visits exceeded recommended model fit indices. The interclass correlation coefficient value (.924) calculated indicated excellent scale reliability and Cronbach’s alpha for subscales PHY and QOL were within recommend values. The MDC value calculated was 5.83 and the MCID for persistent injuries were 2 points and for acute injuries, 3 points. The DPA SF-8 was invariant across time and across subgroups.

Conclusions

The DPA SF-8 met CFA recommendations and criteria for multi-group and longitudinal invariance testing, which indicates the scale may be used to assess for differences between the groups or across time. Our overall analysis indicates the DPA SF-8 is a valid, reliable, and responsive instrument to assess patient improvement in the physically active population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-021-00380-3.

Current Clinical Concepts: Clinical Management of Patellar Tendinopathy

Patellar tendinopathy is a common, yet misunderstood pathoetiology afflicting a variety of patient populations. This lack of unified understanding affects the capability of clinicians to provide effective treatment interventions. Patients with tendinopathy often report long-term and low to moderate levels of pain, diminished flexibility, and strength, as well as decreased physical function. Load-management strategies combined with exercise regimens focused on progressive tendon loading are the most effective treatment option for patients with patellar tendinopathy. This review will provide an evidence-based approach to patellar tendinopathy, including its pathoetiology, evaluation, and treatment strategies.

Chronic ankle instability: Current perspectives

Ankle sprain is reported to be among the most common recurrent injuries. About 20% of acute ankle sprain patients develop chronic ankle instability. The failure of functional rehabilitation after acute ankle sprain leads to the development of chronic ankle instability. Differentiation between functional and anatomical ankle instability is very essential to guide the proper treatment. Stability testing by varus stress test and anterior drawer test should be carried out. Subtalar instability is an important pathology that is commonly by passed during the assessment of chronic ankle instability. Unlike acute ankle sprain, chronic ankle instability might require surgical intervention. The surgical and conservative management options can be very much developed by in-depth knowledge of the ankle anatomy, biomechanics, and pathology. Anatomical repair, augmentation by tendon, or both are the basic methods of surgical intervention. Arthroscopy is becoming more popular in the management of chronic ankle instability.

Impact of kinesiophobia on physical function and quality of life in functional ankle instability individuals: an observational study

Background

Functional ankle instability is a common musculoskeletal condition affecting the community. It is characterized by repetitive bouts of giving away, recurrent sprains, and sensation of instability leading to functional deficits in an individual. The present study aimed to assess the influence of kinesiophobia on physical function and quality of life in participants with functional ankle instability. A cross-sectional study was conducted in 30 participants with functional ankle instability. Kinesiophobia was assessed using the 17-item Tampa Scale of Kinesiophobia, physical function using the Foot and Ankle Ability Measure (FAAM) and the FAAM-Sport version (FAAM-S), and quality of life using SF-36.

Results

The TSK score showed a moderate negative correlation with FAAM-S (r = −0.5, p = 0.005) and a weak negative correlation with SF-36 physical component summary (r = −0.42, p = 0.02). However, TSK showed no significant correlation with FAAM-ADL and SF-36 mental component summary.

Conclusion

Increased fear of movement, reduced physical function, and health-related quality of life were observed in functional ankle instability individuals. Hence, evaluation of these parameters is imperative in these individuals.

Psychological impairments in individuals with history of ankle sprain: a systematic review

Patient-reported outcomes (PROs) can be used to assess and monitor psychological health following musculoskeletal injury. Studies have reported decreased psychological health after lateral ankle sprain (LAS) using numerous PROs. The purpose of this systematic review was to critically evaluate individual studies, summarize PROs utilized to quantify psychological health, and examine the effect of ankle injury on psychological health between groups (1 LAS, >1 LAS, and healthy controls). Databases searched included: CINAHL, MEDLINE, SPORTDiscus, APA, Psychinfo and PubMed Central. All case-control studies were critically appraised using the modified Downs and Black. Effect sizes (ES) were calculated between the groups (1 LAS, >1 LAS, healthy control) for each of the identified studies, for each included PRO used to quantify psychological impairments. Nine high-quality manuscripts were included. Overall, individuals with history of > 1 LAS self-reported greater psychological impairments compared to healthy controls (ES range = -0.37-12.16), while those with 1 LAS had similar psychological health to healthy control groups (ES rang e = -0.65-0.65). Conclusion: The main findings from this systematic review were individuals with > 1 LAS have increased levels of injury-related fear and decreased psychological health compared to healthy controls. PROs can aid clinicians in identifying psychological health concerns during rehabilitation.

Documentation Practices of Athletic Trainers Employed in the Clinic, Physician Practice, and Emerging Clinical Settings

CONTEXT

The documentation practices of athletic trainers (ATs) employed in the secondary school setting, including their strategies for, barriers to, and perceptions of documentation, have been characterized in previous research. The documentation practices of ATs employed in other settings have yet to be studied in depth.

OBJECTIVE

To examine the documentation practices of ATs employed in the clinic, physician practice, and emerging clinical settings.

DESIGN

Qualitative study.

SETTING

Web-based interviews.

PATIENTS OR OTHER PARTICIPANTS

A total of 22 ATs 11 employed in the clinic or physician practice setting and 11 employed in an emerging clinical setting.

DATA COLLECTION AND ANALYSIS

The ATs employed in the settings of interest were recruited with purposeful, convenience, and snowball sampling. Participants were interviewed using a Web-based platform so that we could learn about their behaviors and perceptions of documentation. Data were analyzed using the consensual qualitative research approach, followed by a thematic analysis. Trustworthiness was addressed using data source triangulation, multiple-analyst triangulation, and an established interview guide and codebook.

RESULTS

Participants described following clear guidelines for documentation established by regulatory agencies, employers, and electronic medical record templates. They were motivated to document for patient safety and to demonstrate value. Participants typically documented in real time and continuously, which was facilitated by employer requirements. The ATs described experiencing a learning curve for documentation due to the unique requirements of their settings, but learning was facilitated by employer guidance and mentorship.

CONCLUSIONS

Employer guidelines, training, and ongoing support facilitated effective and thorough documentation in these clinical settings. Athletic trainers and employers in a variety of settings should consider establishing clear guidelines to promote thorough and effective documentation.

The Comparative Mental Health Responses Between Post-Musculoskeletal Injury and Post-Concussive Injury Among Collegiate Athletes: A Systematic Review

BACKGROUND

The average annual national estimate of injuries sustained by collegiate athletes is 210,674, which encompasses both those of a musculoskeletal and a concussive nature. Although athletic injuries are sustained through physical means and produce physical symptoms, sports-related injuries may be a stressor among athletes that is related to mental health.

PURPOSE

The purpose of this systematic review is to summarize existing literature describing mental health responses in collegiate athletes with a concussion compared to those with a musculoskeletal injury.

STUDY DESIGN

Systematic Review.

METHODS

Systematic searches of PubMed, CINAHL, Scopus, ProQuest, and SportDiscus were completed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized. Methodological quality was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Tool. Data extracted from the included articles included the study design, number of participants, type of injury, sex, age, sport participation, outcome measures, and time to return to play.

RESULTS

A total of six articles were included. Peak depressive symptoms in athletes who sustain a concussion or musculoskeletal injury occur within one-week post-injury. No significant differences between the concussive and musculoskeletal groups anxiety scores were found at baseline or at each follow-up session. Athletes from both groups were found to be returning to their respective sports with anxiety scores representative of clinical anxiety.

CONCLUSION

Similar trends in depressive and anxiety symptoms at various time points post-injury were observed in athletes with both musculoskeletal and concussive injuries. This study identified that athletes were returning to play before their psychological symptoms had returned to their baseline.

LEVEL OF EVIDENCE

2a.

Factors associated with musculoskeletal injuries in an infantry commanders course

OBJECTIVES

To evaluate the prevalence of injuries among young combat soldiers as assessed and reported by the military physicians, and to investigate whether parameters such as anthropometric measures, postural balance, proprioceptive ability, and chronic ankle instability are related to injuries during and following an infantry commanders course.

METHODS

In this cross-sectional study, 165 soldiers were tested for anthropometric measurements, proprioceptive ability, and dynamic postural balance (DPB), as well as for their responses to an ankle stability questionnaire (CAIT), on three occasions: pre-course, middle-course, and end-course testing. All musculoskeletal injuries were assessed and recorded in the digital medical file of each participant by specialist military physicians before and during/following the course.

RESULTS

Ninety-eight soldiers (59.4%) were injured before the course. Forty soldiers (24.2%) incurred an injury during/following the course (with 33 out of the 40 [82.5%] soldiers that were injured during/following the course having also been injured before the course). Sixty soldiers had no injury before/during/following the course. A survival curve showed that half of the soldiers who were injured during/following the course (20 soldiers) were recorded as injured in the first half of the course (during the first 46 days of the 92-day course). Logistic regression showed that the pre-course parameters that were significant among injured soldiers compared with the non-injured soldiers were: low CAIT results (OR = 2.736, 95% CI = 1.178-6.354), high BMI (OR = 1.234, 95% CI = 1.082-1.406) and reduced proprioceptive ability (OR =.858, 95% CI =.797-.924).

CONCLUSION

With a high prevalence of soldiers injured during and following a commanders course, a somatosensory intervention program should be generalized into the practical daily preparation and training routines of the soldiers for improving somatosensory abilities, optimizing military physical readiness, and for preventing future musculoskeletal injuries.

Patient-Reported Outcome Measures in Sports Medicine: A Concise Resource for Clinicians and Researchers

BACKGROUND

Despite the importance of assessing patient outcomes during patient care, current evidence suggests relatively limited use of patient-reported outcome measures (PROMs) by athletic trainers (ATs). Major barriers to PROM use include lack of knowledge, navigating the intricate process of assessing a wide variety of PROMs, and selecting the most appropriate PROM to use for care. A concise resource for ATs to consult when selecting and implementing PROMs may help facilitate the use of PROMs in athletic health care.

OBJECTIVE

To review the instrument essentials and clinical utility of PROMs used by ATs.

METHODS

We studied 11 lower extremity region-specific, 10 upper extremity region-specific, 6 generic, and 3 single-item PROMs based on the endorsement of at least 10% of ATs who use PROMs, as reported in a recent investigation of PROM use in athletic training. A literature search was conducted for each included PROM that focused on identifying and extracting components of the instrument essentials (ie, instrument development, reliability, validity, responsiveness and interpretability, and precision) and clinical utility (ie, acceptability, feasibility, and appropriateness). Through independent review and group consensus, we also classified each PROM question by International Classification of Functioning, Disability and Health domain and health-related quality-of-life dimensions.

KEY FINDINGS

The PROMs contained in this report generally possessed appropriate instrument essentials and clinical utility. Moreover, the PROMs generally emphasized body structure and function as well as the physical functioning of the patient. Athletic trainers aiming to assess patients via a whole-person approach may benefit from combining different PROMs for use in patient care to ensure broader attention to disablement health domains and health-related quality-of-life dimensions.

The Impact of a Previous Ankle Injury on Current Health-Related Quality of Life in College Athletes

CONTEXT

There has been an increased interest in understanding how ankle injuries impact patient outcomes; however, it is unknown how the severity of a previous ankle injury influences health-related quality of life (HRQOL).

OBJECTIVE

To determine the impact of a previous ankle injury on current HRQOL in college athletes.

DESIGN

Cross-sectional study.

SETTING

Athletic training clinics.

PARTICIPANTS

A total of 270 participants were grouped by the severity of a previous ankle injury (severe = 62, mild = 65, and no injury = 143).

MAIN OUTCOME MEASURES

Participants completed the Foot and Ankle Ability Measure (FAAM) and the Short Form 12 (SF-12).

METHODS

A 2-way analysis of variance with 2 factors (injury group and sex) was used to identify interaction and main effects for the FAAM and SF-12.

RESULTS

No interactions were identified between injury group and sex. Significant main effects were observed for injury group, where the severe injury group scored lower than athletes with mild and no injuries on the FAAM activities of daily living, FAAM Global, and SF-12 mental health subscale scores. In addition, a main effect was present for sex in the SF-12 general health, social functioning, and mental health subscales in which females reported significantly lower scores than males.

CONCLUSIONS

Our findings suggest that a severe ankle injury impacts HRQOL, even after returning back to full participation. In addition, females tended to report lower scores than males for aspects of the SF-12, suggesting that sex should be considered when evaluating HRQOL postinjury. As a result, clinicians should consider asking athletes about their previous injury history, including how much time was lost due to the injury, and should mindful of returning athletes to play before they are physiologically and psychologically ready, as there could be long-term negative effects on the patients' region-specific function as well as aspects of their HRQOL.

Point-of-Care Clinical Trials in Sports Medicine Research: Identifying Effective Treatment Interventions Through Comparative Effectiveness Research

CONTEXT

Recently, calls to conduct comparative effectiveness research (CER) in athletic training to better support patient care decisions have been circulated. Traditional research methods (eg, randomized controlled trials [RCTs], observational studies) may be ill suited for CER. Thus, innovative research methods are needed to support CER efforts.

OBJECTIVES

To discuss the limitations of traditional research designs in CER studies, describe a novel methodologic approach called the point-of-care clinical trial (POC-CT), and highlight components of the POC-CT (eg, incorporation of an electronic medical record [EMR], Bayesian adaptive feature) that allow investigators to conduct scientifically rigorous studies at the point of care.

DESCRIPTION

Practical concerns (eg, high costs and limited generalizability of RCTs, the inability to control for bias in observational studies) may stall CER efforts in athletic training. In short, the aim of the POC-CT is to embed a randomized pragmatic trial into routine care; thus, patients are randomized to minimize potential bias, but the study is conducted at the point of care to limit cost and improve the generalizability of the findings. Furthermore, the POC-CT uses an EMR to replace much of the infrastructure associated with a traditional RCT (eg, research team, patient and clinician reminders) and a Bayesian adaptive feature to help limit the number of patients needed for the study. Together, the EMR and Bayesian adaptive feature can improve the overall feasibility of the study and preserve the typical clinical experiences of the patient and clinician.

CLINICAL ADVANTAGES

The POC-CT includes the basic tenets of practice-based research because studies are conducted at the point of care, in real-life settings, and during routine clinical practice. If implemented effectively, the POC-CT can be seamlessly integrated into daily clinical practice, allowing investigators to establish patient-reported evidence that may be quickly applied to patient care decisions. This design appears to be a promising approach for CER investigations and may help establish a "learning health care system" in the sports medicine community.

Athletic Trainers' Practice Patterns Regarding Medical Documentation

CONTEXT

Medical documentation is a required component of patient care in all health care professions.

OBJECTIVE

To evaluate athletic trainers' perceived behaviors toward, barriers to, and confidence in their medical documentation.

DESIGN

Cross-sectional study.

SETTING

Web-based survey.

PATIENTS OR OTHER PARTICIPANTS

We purchased a list of randomly selected e-mails from the National Athletic Trainers' Association. Of the 9578 participants, 1150 accessed our questionnaire (12.0% access rate), 1053 completed at least 1 portion, and 904 completed the questionnaire in its entirety (85.8% completion rate). Of the participants, 60.1% (n = 569/947) were female, 66.6% (n = 632/949) held a master's degree, 39.3% (n = 414/1053) worked in a collegiate or university setting, and 36.1% (n = 381/1053) worked in a secondary school setting.

MAIN OUTCOME MEASURE(S)

We used a 31-item questionnaire with demographics (12 items), medical documentation behaviors (16 items), barriers (2 items), and perceptions (1 multipart item) sections. The questionnaire explored athletic trainers' behaviors as well as confidence in, comfort with, and concerns about their documentation practices (Cronbach α = 0.887). We used descriptive statistics to identify characteristics of central tendency (mean, standard deviation, mode, frequency).

RESULTS

Participants always (45.7%, n = 478/1046) or very frequently (39.0%, n = 408/1046) used a double documentation system consisting of electronic and paper records (50.4%, n = 523/1038). They most often documented to provide legal protection (86.8%, n = 914/1053), because it is a legal obligation (79.1%, n = 833/1053), or to track patient progress (83.9%, n = 883/1053). The most frequently cited barriers to medical documentation were time (76.5%, n = 806/1053), managing too many patients (51.9%, n = 547/1053), technological concerns (17.2%, n = 181/1053), and software limitations (17.2%, n = 181/1053). Respondents believed they were competent, comfortable, and confident in their documentation practices.

CONCLUSIONS

We were able to evaluate the generalizability of previous research while adding to the understanding of the behaviors toward, barriers to, and perceptions about medical documentation. We confirmed that time and patient load affected the ability to perform high-quality medical documentation.

An Updated Model of Chronic Ankle Instability

Lateral ankle sprains (LASs) are among the most common injuries incurred during participation in sport and physical activity, and it is estimated that up to 40% of individuals who experience a first-time LAS will develop chronic ankle instability (CAI). Chronic ankle instability is characterized by a patient's being more than 12 months removed from the initial LAS and exhibiting a propensity for recurrent ankle sprains, frequent episodes or perceptions of the ankle giving way, and persistent symptoms such as pain, swelling, limited motion, weakness, and diminished self-reported function. We present an updated model of CAI that aims to synthesize the current understanding of its causes and serves as a framework for the clinical assessment and rehabilitation of patients with LASs or CAI. Our goal was to describe how primary injury to the lateral ankle ligaments from an acute LAS may lead to a collection of interrelated pathomechanical, sensory-perceptual, and motor-behavioral impairments that influence a patient's clinical outcome. With an underpinning of the biopsychosocial model, the concepts of self-organization and perception-action cycles derived from dynamic systems theory and a patient-specific neurosignature, stemming from the Melzack neuromatrix of pain theory, are used to describe these interrelationships.

A Perceptual Framework for Conservative Treatment and Rehabilitation of Ankle Sprains: An Evidence-Based Paradigm Shift

Lateral ankle sprains are the most common injuries sustained during physical activity. The epidemiologic trends associated with chronic ankle instability (CAI) suggest that current rehabilitation approaches may be inadequate. We sought to synthesize best-practices evidence for the rehabilitation of patients with acute ankle sprains and CAI through the integration of emerging paradigms in perception, the dynamics of skill acquisition, and the biopsychosocial model of function, disability, and health. From the best available evidence, 4 key factors emerged for effective treatment and rehabilitation strategies: pain reduction, external ankle support for up to 1 year, progressive return to motion, and coordination training. We combined these factors into a meta-theoretical framework that centers on the perceptual interdependence of the cellular, local, and global functioning levels by linking insights from the body-self neuromatrix, the dynamics of skill acquisition, and the biopsychosocial model. Based on the best-practice recommendations from systematic reviews, ankle-sprain rehabilitation represents a multidimensional phenomenon governed by perception. The impairments, activity limitations, and participation restrictions associated with CAI may be linked to perceptual-interdependence alterations. Pain and edema reduction, the use of external ankle support for up to 1 year, progressive return to motion, and coordination training foster enhanced perceptual interdependence from cells to society. Using the perceptual-interdependence framework for ankle-sprain rehabilitation, we offer new insights for charting the course of effective strategies for enhancing function, reducing disability, and preventing the long-term sequelae associated with CAI.

Appropriate Medical Care Standards for Organizations Sponsoring Athletic Activity for the Secondary School-Aged Athlete: A Summary Statement

OBJECTIVE

To present the appropriate medical care standards for organizations that sponsor athletic activities for secondary school-aged athletes.

DATA SOURCES

To develop the current standards and identify current best-practices evidence, the task force used a multistep process that included reviewing the existing 2004 Appropriate Medical Care for Secondary School-Aged Athletes consensus points and cross-referencing of National Athletic Trainers' Association (NATA) statements and official documents from the strategic alliance (the NATA, NATA Foundation, Board of Certification, and Commission on Accreditation of Athletic Training Education). Gaps in the recommendations from the 2004 Appropriate Medical Care for Secondary School-Aged Athletes document were identified by the task force, and the new appropriate medical care standards were developed and refined.

CONCLUSIONS AND RECOMMENDATIONS

Twelve standards, with supporting substandards, were developed that encompassed readiness to participate in activity; facilities; equipment; protective materials; environmental policies; nutrition, hydration, and dietary supplementation; wellness and long-term health; comprehensive emergency action plans; on-site immediate care; on-site therapeutic interventions; psychological concerns; and athletic health care administration. Collectively, these standards describe a comprehensive approach to providing appropriate health care to secondary school-aged athletes and should serve as a framework with which organizations can evaluate and improve the medical care supplied to adolescent athletes.

Use of Patient-Reported Outcome Measures in Athletic Training: Common Measures, Selection Considerations, and Practical Barriers

CONTEXT

Current evidence suggests that a low percentage of athletic trainers (ATs) routinely use patient-reported outcome measures (PROMs). An understanding of the perceptions of ATs who use (AT-USE) and who do not use (AT-NON) PROMs as well as any differences due to demographic characteristics (eg, use for patient care or research, job setting, highest education level) may help facilitate the use of PROMs in athletic training.

OBJECTIVE

To describe commonly used PROMs by AT-USE, the criteria by which AT-USE select PROMs, and reasons for non-use by AT-NON.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

A convenience sample of 1784 ATs (response rate = 10.7% [1784/17972]; completion rate = 92.2% [1784/1935]) who worked in a variety of settings.

MAIN OUTCOME MEASURE(S)

Participants completed an anonymous electronic online survey. Descriptive statistics were used to describe commonly used PROMs, PROM selection criteria, and reasons for PROM non-use.

RESULTS

Participants were classified as AT-USE (n = 370, 20.7%) or AT-NON (n = 1414, 79.3%). For the AT-USE group, the most common type of PROMs used were specific (eg, region, joint; n = 328, 88.6%), followed by single-item (n = 258, 69.7%) and generic (n = 232, 62.7%). Overall, the PROMs most frequently endorsed by the AT-USE group were the Numeric Pain Rating Scale (n = 128, 34.6%); Lower Extremity Functional Scale (n = 108, 29.2%); Disability of the Arm, Shoulder and Hand (n = 96, 25.9%); Owestry Disability Index (n = 80, 21.6%); and Foot and Ankle Ability Measure (n = 78, 21.1%). The most important criteria reported by AT-USE for selecting PROMs were that the measure was valid and reliable, easy for patients to understand, and easy for clinicians to understand and interpret. Common reasons for non-use were that PROMs were too time consuming for the clinician, too time consuming for the patient, and more effort than they were worth.

CONCLUSIONS

The Numeric Pain Rating Scale; Lower Extremity Functional Scale; Disability of the Arm, Shoulder and Hand; Owestry Disability Index; and Foot and Ankle Ability Measure were the PROMs most commonly endorsed by AT-USE and should be considered for athletic training use. To further facilitate the use of PROMs in athletic training, future authors should identify strategies to address organizational and time-constraint obstacles. Interpretation of our study findings may require caution due to a relatively low response rate and because "routine use" was not operationalized.

Confirmatory Factor Analysis of the Disablement in the Physically Active Scale and Preliminary Testing of Short-Form Versions: A Calibration and Validation Study

CONTEXT

The Disablement in the Physically Active (DPA) scale is a patient-reported outcome instrument recommended for use in clinical practice and research. Analysis of the scale has indicated a need for further psychometric testing.

OBJECTIVE

To assess the model fit of the original DPA scale using a larger and more diverse sample and explore the potential for a short-form (SF) version.

DESIGN

Observational study.

SETTING

Twenty-four clinical settings.

PATIENTS OR OTHER PARTICIPANTS

Responses were randomly split into 2 samples: sample 1 (n = 690: 353 males, 330 females, and 7 not reported; mean age = 23.1 ± 9.3 years, age range = 11-75 years) and sample 2 (n = 690: 351 males, 337 females, and 2 not reported; mean age = 22.9 ± 9.3 years, age range = 8-74 years). Participants were physically active individuals who were healthy or experiencing acute, subacute, or persistent musculoskeletal injury.

MAIN OUTCOME MEASURE(S)

Confirmatory factor analysis was conducted to assess the factor structure of the original DPA scale. Exploratory factor, internal consistency, covariance modeling, correlational, and confirmatory factor analyses were conducted to assess potential DPA scale SFs.

RESULTS

The subdimensions of the disablement construct were highly correlated (≥0.89). The fit indices for the DPA scale approached recommended levels, but the first-order correlational values and second-order path coefficients provided evidence for multicollinearity, suggesting that clear distinctions between the disablement subdimensions cannot be made. An 8-item, 2-dimensional solution and a 10-item, 3-dimensional solution were extracted to produce SF versions. The DPA SF-8 was highly correlated (r = 0.94, P ≤ .001, R² = 0.88) with the DPA scale, and the fit indices exceeded all of the strictest recommendations. The DPA SF-10 was highly correlated (r = 0.97, P ≤ .001, R² = 0.94) with the DPA scale, and its fit indices values also exceeded the strictest recommendations.

CONCLUSIONS

The DPA SF-8 and SF-10 are psychometrically sound alternatives to the DPA scale.

The Use of Patient-Reported Outcome Measures: Secondary School Athletic Trainers' Perceptions, Practices, and Barriers

CONTEXT

Incorporating patient-reported outcomes (PROs) into daily routine is essential for patient-centered clinical practice. Secondary school athletic trainers (ATs) may encounter unique barriers that limit their willingness to use PROs.

OBJECTIVE

To explore how secondary school ATs who were using PROs perceived their application, benefits, and problems compared with those who did not.

DESIGN

Cross-sectional study.

SETTING

Web-based survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 2984 secondary school ATs received an e-mail invitation, and 322 completed the survey (response rate = 10.8%). Respondents were 43 ± 10 years old, with most indicating at least 11 years as a Board of Certification-certified AT (n = 276, 85.7%).

MAIN OUTCOME MEASURE(S)

The ATs were invited to complete a Web-based survey regarding the uses and benefits of and problems with PROs. Those using PROs in clinical practice were asked their criteria for selecting the measures, whereas those not using PROs were asked their reasons for not using them. Dependent variables were endorsements of uses and benefits of and problems with PROs.

RESULTS

The most commonly cited uses of PROs were determining treatment effectiveness (193/264, 73%) and demonstrating effectiveness to administration (174/264, 66%). Improving communication with the patient (267/296, 90%) and helping to direct the plan of care (256/297, 86%) were the most frequently endorsed benefits of PROs. Time to score and analyze (152/284, 53%) and time for patients to complete (134/284, 47%) PROs were the problems encountered most often. For ATs not using PROs (223/262, 85%), the most frequent reason was the lack of a support structure (102/219, 46%). For ATs using PROs (39/262, 15%), quick completion times (32/39, 82%) was the most common criterion used to select individual measures.

CONCLUSIONS

A majority of secondary school ATs recognized the benefits of PROs and yet did not use them in clinical practice due to setting-specific barriers.

The Impact of Knee Injury History on Health-Related Quality of Life in Adolescent Athletes

CONTEXT

Current evidence suggests that, despite returning to full participation, physically active adults with a previous knee injury experience lower health-related quality of life (HRQOL) than those with no knee injury history. It is unknown if this relationship is present in adolescent athletes.

OBJECTIVE

To determine the impact of knee injury history on HRQOL in adolescent athletes who were medically cleared for full participation.

DESIGN

Cross-sectional.

SETTING

Athletic training clinics.

PARTICIPANTS

A convenience sample of 183 adolescent athletes, who were medically cleared for full participation, were grouped by self-report of a previous knee injury: positive knee injury history (HIS; n = 36, age = 15.7 [1.4] y, height = 168.0 [11.9] cm, and weight = 71.8 [11.9] kg) and no knee injury history (NO-HIS; n = 147, age = 15.5 [1.4] y, height = 166.0 [10.5] cm, and weight = 67.6 [14.6] kg).

INTERVENTIONS

Participants completed the Pediatric International Knee Documentation Committee form and Pediatric Quality of Life Inventory during their preparticipation examination.

MAIN OUTCOME MEASURES

Generalized linear models were used to compare group differences for the total and subscale scores of the Pediatric International Knee Documentation Committee and Pediatric Quality of Life Inventory.

RESULTS

Main effects of injury group indicated that the HIS group reported significantly lower scores than the NO-HIS group for the Pediatric International Knee Documentation Committee total score (P < .001; HIS = 79.2 [21.7], NO-HIS = 95.8 [8.6]) and for the Pediatric Quality of Life Inventory total (P = .001; HIS = 85.7 [10.9], NO-HIS = 90.9 [7.3]), physical functioning (P = .002; HIS = 86.7 [13.6], NO-HIS = 92.1 [8.2]), school functioning (P = .01; HIS = 80.6 [12.4], NO-HIS = 86.8 [12.2]), and social functioning (P = .01; HIS = 89.3 [12.4], NO-HIS = 94.6 [8.9]) scores. No group differences were reported for the emotional functioning subscale (P = .13; HIS = 85.7 [17.7], NO-HIS = 89.7 [13.1]). No interactions or main effects of sex were reported (P > .05).

CONCLUSIONS

Our findings suggest that, despite returning to full sport participation, adolescent athletes with a previous knee injury generally experience lower HRQOL than their peers with no knee injury history, specifically for knee-specific HRQOL, physical functioning, school functioning, and social functioning. Our results are similar to previous findings reported in college athletes and military cadets.

Disablement Model and Health-Related Quality of Life Classification for Patient-Reported Outcomes Measurement Information System (PROMIS) Instruments

CONTEXT

The National Institutes of Health created a medical research road map that included the development of the Patient-Reported Outcomes Measurement Information System (PROMIS). A key feature of PROMIS was the development of patient-reported outcome measures (PROs) addressing various aspects of health. Understanding disablement dimensions and health-related quality-of-life (HRQOL) domains captured through PROMIS measures will help with instrument selection.

OBJECTIVE

To evaluate the pediatric PROMIS PROs and determine the areas of disablement and HRQOL captured within each instrument.

DESIGN

Descriptive laboratory study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

Twenty-two pediatric PROMIS instruments (19 short forms and 3 profiles).

MAIN OUTCOME MEASURE(S)

Three raters independently reviewed the PROMIS instruments and categorized each question on each instrument according to the World Health Organization's International Classification of Functioning, Disability, and Health disablement model domains (body functions and structures, activity, participation, environmental factors, personal factors) and HRQOL (psychological, physical, social, spiritual, economic) dimensions. A consensus process determined the final question category. The frequencies of disablement model domains and HRQOL dimensions captured by questions on PROMIS instruments were reported.

RESULTS

The most frequently reported disablement model domain was body function and structure, which was captured by questions in 16/22 (73%) pediatric PROMIS instruments, followed by activity (13/22 [59%] pediatric PROMIS instruments) and participation (9/22 [41%] pediatric PROMIS instruments). The most frequently captured HRQOL dimensions were physical and psychological health, both evaluated in 13/22 (59%) of the pediatric PROMIS instruments. The social dimension of HRQOL was assessed in 9/22 (41%) of the pediatric PROMIS instruments.

CONCLUSIONS

Pediatric PROMIS fixed-length instruments captured a variety of disablement domains and health dimensions, but, like most PRO instruments, no single PROMIS instrument captured them all. Clinicians and researchers must consider their goals when selecting PRO instruments, which may require implementing multiple instruments and those beyond PROMIS.

The Long-Term Impact of Osteoarthritis Following Knee Surgery in Former College Athletes

CONTEXT

Individuals who sustain a knee surgery have been shown to have an increased likelihood to develop osteoarthritis (OA).

OBJECTIVE

Identify the consequences of knee surgery in a cohort of former college athletes.

DESIGN

Cross-sectional.

SETTING

Research laboratory.

PARTICIPANTS

A group of 100 former Division I college athletes aged 40-65 years (60 males and 40 females) participated in the study.

INTERVENTIONS

All individuals self-reported whether they sustained a knee injury during college requiring surgery and if they have been diagnosed with knee OA by a medical physician post knee injury. Individuals were categorized into 3 groups: no history of knee injury requiring surgery (33 males and 24 females; 54.53 [5.95] y), history of knee surgery in college with no diagnosis of OA later in life (4 males and 6 females; 51.26 [7.29] y), and history of knee surgery in college with physician diagnosed OA later in life (23 males and 10 females; 54.21 [7.64] y). All individuals completed the knee injury and osteoarthritis outcome score (KOOS) and short form-36 version 2.

MAIN OUTCOME MEASURES

Scores on the KOOS and short form-36 version 2.

RESULTS

A majority (76.7%) of individuals who had a knee surgery in college did develop OA. The largest mean differences were between the healthy knee and surgical knee/OA groups on the KOOS-quality of life scale (mean difference: 49.76; χ2(3) = 44.65; P < .001) and KOOS-sports scale (mean difference: 43.69; χ2(3) = 28.69; P < .001), with the surgical knee/OA group scoring worse.

CONCLUSIONS

Later in life functional limitations were observed in individuals who sustained a knee injury requiring surgery and developed OA. These findings support increased efforts toward prevention of knee injuries and consideration of the long-term implication when making treatment and return to activity decisions.

Validity and Responsiveness of the Single Alpha-numeric Evaluation for Shoulder Patients

BACKGROUND

There is an ever-increasing demand for widespread implementation of patient-reported outcomes. However, adoption is slow owing to limitations in clinical infrastructure and resources within busy orthopaedic practices. Prior studies showed the single alpha-numeric evaluation (SANE) score to correlate at a single point in time with the American Shoulder and Elbow Surgeons (ASES) score. However, no study has validated the SANE in terms of test-retest reliability, responsiveness, or clinical utility.

PURPOSE

To validate SANE with the ASES across a sample of patients with common orthopaedic shoulder diagnoses.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Patients undergoing rotator cuff repair (n = 77), total shoulder replacement (n = 55), or physical therapy (n = 80) for signs and symptoms of subacromial impingement syndrome (n = 61) or adhesive capsulitis (n = 19) were administered the SANE and ASES at baseline and again at their 3-month follow-up from initial care or surgery (N = 212, mean ± SD age = 52.6 ± 1.2 years, n = 145 women). Interclass correlation coefficient (ICC_2,1) and standard error of the measurement (SEm) were used to evaluate the test-retest reliability of the SANE and the validity between the SANE and ASES scores. Analysis of variance (treatment group × time) was used to evaluate the responsiveness to treatment, and a receiver operating characteristic curve was used to establish the minimal clinically important difference (MCID) for the SANE as compared with the ASES (α = .05). Floor and ceiling effects were evaluated as the percentage of patients who scored the highest or lowest score on each tool.

RESULTS

The SANE demonstrated good pretreatment reliability (ICC_2,1 = 0.84, SEM = 3.8), similar to the ASES (ICC_2,1 = 0.82, SEM = 3.4). The SANE also showed good agreement with the ASES before and after treatment across all treatment groups (rotator cuff repair, ICC_2,1 = 0.85, SEM = 3.4; total shoulder replacement, ICC_2,1 = 0.72, SEM = 5.2; physical therapy: ICC_2,1 = 0.82, SEM = 2.9). The SANE and ASES displayed similar responsiveness after treatment, with similar mean change and SD within each treatment group. The receiver operating characteristic curve revealed an area under the curve of 0.79 (SE, 0.62; P < .001) and a cutoff of 15% on the SANE, with a sensitivity of 85% to establish the MCID. Acceptable and similar floor and ceiling effects were observed for the ASES (4%) and SANE (9%).

CONCLUSION

The study demonstrates that the SANE is valid for a range of common shoulder diagnoses to assess patient outcomes across operative and nonoperative treatment for shoulder complaints. The MCID of 15% is similar to that of the ASES (11%), suggesting that the SANE is a simple and efficient tool to assess treatment effects for shoulder disorders. Future studies are warranted to confirm these results and compare across other body parts and diagnoses.

Health-Related Quality of Life Following Concussion in Collegiate Student-Athletes With and Without Concussion History

The purpose of this study was to compare global and specific health-related quality of life (HRQOL) throughout concussion recovery between those with and without concussion history. Student-athletes diagnosed with concussion completed global (Short Form-12v2; SF-12) and specific (Hospital Anxiety and Depression Scale: HADS) HRQOL assessments at baseline, 24-48 h, asymptomatic, return-to-play, and 6-months post-injury. Baseline scores were compared to post-injury time points for SF-12 subscores (physical and mental; PCS-12, MCS-12) and HADS subscores (depression and anxiety; HADS-D, HADS-A). We conducted a 2 × 5 mixed model ANOVA for group (with and without concussion history) and time (four post-injury assessments compared to baseline). We did not observe interaction or main effects for group, except those with concussion history had worse HADS-D subscores than those without concussion history. PCS-12 subscores were worse at 24-48 h, asymptomatic, and return-to-play compared to baseline, but returned to baseline 6-months post-injury. MCS-12 subscores did not differ at any time points. HADS-D subscores worsened 24-48 h post-injury, but improved for additional assessments compared to baseline. HADS-A improved post-injury compared to baseline at asymptomatic, return-to-play, and 6-month assessments, but was similar to baseline 24-48 h post-injury. HRQOL physical aspects slightly worsened post-injury and restored to baseline after returning to play.

Examination of Response Shift After Rehabilitation for Orthopedic Conditions: A Systematic Review

CONTEXT

There is an increased emphasis on the need to capture and incorporate self-reported function to make clinical decisions when providing patient-centered care. Response shift (RS), or a change in an individual's self-evaluation of a construct, may affect the accurate assessment of change in self-reported function throughout the course of rehabilitation. A systematic review of this phenomenon may provide valuable information regarding the accuracy of self-reported function.

OBJECTIVES

To systematically locate and synthesize the existing evidence regarding RS during care for various orthopedic conditions.

EVIDENCE ACQUISITION

Electronic databases (PubMed, MEDLINE, CINAHL, SPORTDiscus, and Psychology & Behavioral Sciences Collection) were searched from inception to November 2016. Two investigators independently assessed methodological quality using the modified Downs and Black Quality Index. The quality of evidence was assessed using the Strength-of-Recommendation Taxonomy. The magnitude of RS was examined through effect sizes.

EVIDENCE SYNTHESIS

Nine studies were included (7 high quality and 2 low quality) with a median Downs and Black Quality Index score of 81.25% (range = 56.25%-93.75%). Overall, the studies demonstrated weak to strong effect sizes (range = -1.58-0.33), indicating the potential for RS. Of the 36 point estimates calculated, 22 (61.11%), 2 (5.56%), and 12 (33.33%) were associated with weak, moderate negative, and strong negative effect sizes, respectively.

CONCLUSIONS

There is grade B evidence that a weak RS, in which individuals initially underestimate their disability, may occur in people undergoing rehabilitation for an orthopedic condition. It is important for clinicians to be aware of the potential shift in their patients' internal standards, as it can affect the evaluation of health-related quality of life changes during the care of orthopedic conditions. A shift in the internal standards of the patient can lead to subsequent misclassification of health-related quality of life changes that can adversely affect clinical decision making.

Does Multimodal Rehabilitation for Ankle Instability Improve Patients' Self-assessed Functional Outcomes? A Network Meta-analysis

BACKGROUND

Although there are many nonsurgical treatment options for the primary management of chronic ankle instability, the most effective nonoperative intervention has not been defined.

QUESTIONS/PURPOSES

The purpose of this study was to perform a network meta-analysis to compare the results of different standalone and/or combined nonsurgical interventions on chronic ankle instability as measured by (1) the Cumberland Ankle Instability Tool (CAIT) at 0 to 6 months after treatment and (2) treatment-related complications.

METHODS

We searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus in August 2017 for completed studies published between 2005 and 2016. We conducted random-effects pairwise and network meta-analysis considering randomized trials, which compared the effects of various nonoperative therapies for ankle instability. Studies assessing patients with functional ankle instability and/or mechanical ankle instability and/or recurrent ankle sprains were eligible for inclusion. After combining data from self-administered questionnaires, we analyzed patient self-reported outcomes of function at the end of the rehabilitation period and 1 to 6 months after treatment. We thereafter reexpressed standardized mean differences to mean differences with CAIT. For this instrument, scores vary between 0 and 30, and higher scores indicate better ankle stability. We included 21 trials involving 789 chronically unstable ankles. The rehabilitation interventions included, but were not limited to, balance training, strengthening exercises, a combination of the balance and strengthening exercises, manual therapy, and multimodal treatment. The implemented multistation protocols were targeted at four main areas of rehabilitation (ROM, balance, strength, and overall activity). Control was defined as placebo and/or wait and see. Treatment-related complications were defined as any major or minor adverse event observed after rehabilitation as reported by the source studies. Statistically, we did not detect significant inconsistency in the network meta-analysis. We also assessed the quality of the trials using the Cochrane risk of bias tool and judged 12, eight, and one studies to be at a low, unclear, and high risk of bias, respectively. We also considered the quality of evidence to be of moderate strength utilizing the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. We defined the minimum clinically important difference (MCID) in the CAIT to be 3 points.

RESULTS

A 4-week supervised rehabilitation program, which included balance training, strengthening, functional tasks, and ROM exercises, was favored over control according to the results of four trials by a clinically important margin (mean difference between multimodal and control groups in the CAIT was -10; 95% confidence interval [CI], -16 to -3; p = 0.001). Among the standalone interventions, only balance training was better than control according to the findings of seven trials (mean difference between balance training and control in the CAIT was -5; 95% CI, -10 to -0.03; p = 0.049); this difference likewise exceeded the MCID and so is believed to be a clinically important difference. Adverse events associated with the enrolled rehabilitation protocols were transient, mild, and uncommon.

CONCLUSIONS

Although a supervised impairment-based program after chronic ankle instability was superior to control, we note that followup in the included trials tended to be short and inconsistent, although the effect size exceeded the MCID and so likely would be identified as clinically important by patients. Future randomized trials should determine whether the short-term benefits of these interventions are sustained over time.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Reliability, minimal detectable change, and responsiveness of the Quick-FAAM

OBJECTIVE

To determine the test-retest reliability, minimal detectable change (MDC) and responsiveness of the Quick-FAAM in people with chronic ankle instability (CAI).

DESIGN

10-week controlled laboratory study.

SETTING

Laboratory.

PARTICIPANTS

A total of 20 adults with self-reported CAI.

MAIN OUTCOME MEASURES

Participants completed a supervised 4-week intervention. The Quick-FAAM was assessed 4-weeks before the intervention (T1), prior to the first intervention (T2), 24-h post-intervention (T3), and 2-weeks after the intervention (T4). The Quick-FAAM is a 12-item region specific PRO scored on 5-point Likert scale, often reported as a percentage, and a lower percentage indicates decreased ankle function. Test-retest reliability was determined using Intraclass-correlation coefficients (ICC_2,1) and standard error of measure (SEM). The MDC was calculated using the equation: SEM*√2. Hedges g effect sizes and associated 95% confidence intervals (95%CI) were calculated as a measure of group responsiveness.

RESULTS

The test-retest reliability was clinically acceptable (ICC_2,1 = 0.82, SEM = 4.56). The MDC was 6.5% and pre-post intervention effect sizes were large between T2-T3 (ES = 1.27, 95%CI:0.59-1.95) and T2-T4 (ES = 1.49, 95%CI:0.79-2.19).

CONCLUSION

The Quick-FAAM demonstrated clinically acceptable reliability and was responsive to treatment. Future research should examine these properties in patients with acute ankle and foot conditions, determine patient acceptability, and clinician feasibility.

Lived Experiences of Adolescent Athletes Following Sport-Related Concussion

Background:

Previous studies have identified the effect of sport-related concussion on health-related quality of life through the use of patient-reported outcome measures. However, there has been little research exploring the underlying mechanisms that influence these perceptions of health-related quality of life among adolescent athletes who have sustained a sport-related concussion.

Purpose:

To explore the psychosocial aspects of concussion among adolescent athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 12 interscholastic athletes (4 girls, 8 boys; mean ± SD age, 15.7 ± 1.7 years; grade level, 10.2 ± 1.4) were interviewed via a semistructured interview protocol between 15 and 30 days postinjury. Data analysis was guided by the consensual qualitative research tradition. Themes and categories emerged through consensus by a 3-person research team, and bias was minimized through the use of multiple-analyst triangulation.

Results:

Participants identified numerous postconcussion symptoms that resulted in increasing difficulty with emotions (eg, irritable, easily frustrated), roles at school (eg, concentration difficulties, fatigue), and roles in their social environment (eg, letting the team down, not being able to contribute to sport). As a result, participants expressed how they tried to minimize or mask symptoms to decrease the potential of being viewed differently by their peers.

Conclusion:

Adolescent athletes perceived a significant effect of sport-related concussion on numerous areas of psychosocial and emotional health and well-being. Anticipatory guidance—with education regarding the possible signs and symptoms, risk factors, and recovery expectations following a concussion—is important to include in postinjury management. A better understanding of sport-related concussion and expected recovery could help to improve perceptions of this injury among interscholastic athletes. Additionally, best practices should be identified to assist health care professionals and school personnel in the development of temporary adjustments or formal academic adjustment policies in the secondary school setting, therefore ensuring that the patients receive the support that they need to maintain their roles as students.

Quality Improvement in Athletic Health Care

CONTEXT

  Quality improvement (QI) is a health care concept that ensures patients receive high-quality (safe, timely, effective, efficient, equitable, patient-centered) and affordable care. Despite its importance, the application of QI in athletic health care has been limited.

OBJECTIVES

  To describe the need for and define QI in health care, to describe how to measure quality in health care, and to present a QI case in athletic training.

DESCRIPTION

  As the athletic training profession continues to grow, a widespread engagement in QI efforts is necessary to establish the value of athletic training services for the patients that we serve. A review of the importance of QI in health care, historical perspectives of QI, tools to drive QI efforts, and examples of common QI initiatives is presented to assist clinicians in better understanding the value of QI for advancing athletic health care and the profession. Clinical and Research Advantages:  By engaging clinicians in strategies to measure outcomes and improve their patient care services, QI practice can help athletic trainers provide high-quality and affordable care to patients.

Association between body composition and stair negotiation ability among individuals >55 years of age: a cross-sectional study

Background

Loss of muscle strength exerts a considerable impact on the quality of life and mortality of older adults. The present household survey study measured body composition and muscle strength with the aim of analyzing the roles of low lean mass, low muscle strength and obesity in stair negotiation ability and the effect of comorbidities on the relationship between body composition and functional capacity.

Methods

Body composition was assessed using bioelectrical impedance analysis and muscle strength was assessed with a hand grip dynamometer. The study population comprised individuals >55 years of age from a medium-sized Brazilian municipality. The sample included 451 participants.

Results

A total of 368 subjects were interviewed; their ages varied from 56 to 91 years. Among males, low muscle strength was associated with stair negotiation difficulty independent of muscle mass, age and obesity but muscle mass was not. However, when we analyzed comorbidities and body composition jointly, chronic lower limb pain and obesity were independently associated with stair negotiation difficulty but body composition and age were not. Among women, after comorbidities were included into the model, low muscle strength and obesity remained associated with stair negotiation difficulty as chronic lower limb pain and depression. The relationship between muscle function and comorbidities is discussed in this article.

Rehabilitation and Improvement of Health-Related Quality-of-Life Detriments in Individuals With Chronic Ankle Instability: A Meta-Analysis

OBJECTIVE

  To conduct a systematic review with meta-analysis assessing the effectiveness of conservative rehabilitation programs for improving health-related quality of life (HRQL) in individuals with chronic ankle instability (CAI).

DATA SOURCES

  PubMed, MEDLINE, CINAHL, and SPORTDiscus were searched from inception to January 2016.

STUDY SELECTION

  Studies were included if the researchers examined the effects of a conservative rehabilitation protocol in individuals with CAI, used validated patient-reported outcomes (PROs) to quantify participant-perceived HRQL, and provided adequate data to calculate the effect sizes (ESs) and 95% confidence intervals (CIs). Studies were excluded if the authors evaluated surgical interventions, prophylactic taping, or bracing applications or examined only the immediate effects of 1 treatment session.

DATA EXTRACTION

  Two investigators independently assessed methodologic quality using the Physiotherapy Evidence Database (PEDro) Scale. Studies were considered low quality if fewer than 60% of the criteria were met. Level of evidence was assessed using the Strength of Recommendation Taxonomy. Preintervention and postintervention sample sizes, means, and standard deviations of PROs were extracted.

DATA SYNTHESIS

  A total of 15 studies provided 24 participant groups that were included in the analysis. Seven high-quality studies with a median PEDro score of 50% (range = 10%-80%) and a median level of evidence of 2 (range = 1-2) were identified. The magnitudes of preintervention to postintervention PRO differences were examined using bias-corrected Hedges g ESs. Random-effects meta-analysis was performed to synthesize PRO changes across all participant groups. Positive ES values indicated better PRO scores at postintervention than at preintervention. The α level was set at .05. Meta-analysis revealed a strong ES with a nonoverlapping 95% CI (ES = 1.20, CI = 0.80, 1.60; P < .001), indicating HRQL improved after conservative rehabilitation.

CONCLUSIONS

  Based on the quality of the evidence and the results of the meta-analysis, grade A evidence showed that conservative rehabilitation produces large improvements in HRQL for people with CAI.

Athletic Trainers' Reasons for and Mechanics of Documenting Patient Care: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

  Documenting patient care is an important responsibility of athletic trainers (ATs). However, little is known about ATs' reasons for documenting patient care and the mechanics of completing documentation tasks.

OBJECTIVE

  To understand ATs' perceptions about reasons for and the mechanics of patient care documentation.

DESIGN

  Qualitative study.

SETTING

  Individual telephone interviews with Athletic Training Practice-Based Research Network members.

PATIENTS OR OTHER PARTICIPANTS

  Ten ATs employed in the secondary school setting (age = 32.6 ± 11.4 years, athletic training experience = 7.1 ± 7.8 years) were recruited using a criterion-based sampling technique. Participants were Athletic Training Practice-Based Research Network members who used the Clinical Outcomes Research Education for Athletic Trainers electronic medical record system and practiced in 6 states.

DATA COLLECTION AND ANALYSIS

  We used the consensual qualitative research tradition. One investigator conducted individual telephone interviews with each participant. Data collection was considered complete after the research team determined that data saturation was reached. Interviews were transcribed verbatim and independently analyzed by 4 research team members following the process of open, axial, and selective coding. After independently categorizing interview responses into categories and themes, the members of the research team developed a consensus codebook, reanalyzed all interviews, and came to a final agreement on the findings. Trustworthiness was established through multiple-analyst triangulation and member checking.

RESULTS

  Participants identified 3 reasons for documenting patient care: communication, monitoring patient care, and legal implications. Four subcategories emerged from the mechanics-of-documentation theme: location, time of day, length of time, and criteria for documenting. The ATs described different criteria for documenting patient care, ranging from documenting every injury in the same manner to documenting time-loss and follow-up injuries differently.

CONCLUSIONS

  Whereas ATs recognized individual mechanisms that enabled them to document patient care, they may need more guidance on the appropriate criteria for documenting various patient care encounters and strategies to help them document more effectively.

The Functional Arm Scale for Throwers (FAST)-Part I: The Design and Development of an Upper Extremity Region-Specific and Population-Specific Patient-Reported Outcome Scale for Throwing Athletes

BACKGROUND

Upper extremity (UE) region-specific, patient-reported outcome (PRO) scales assess injuries to the UE but do not account for the demands of overhead throwing athletes or measure patient-oriented domains of health-related quality of life (HRQOL).

PURPOSE

To develop the Functional Arm Scale for Throwers (FAST), a UE region-specific and population-specific PRO scale that assesses multiple domains of disablement in throwing athletes with UE injuries. In stage I, a beta version of the scale was developed for subsequent factor identification, final item reduction, and construct validity analysis during stage II.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Three-stage scale development was utilized: Stage I (item generation and initial item reduction) and stage II (factor analysis, final item reduction, and construct validity) are reported herein, and stage III (establishment of measurement properties [reliability and validity]) will be reported in a companion paper. In stage I, a beta version was developed, incorporating National Center for Medical Rehabilitation Research disablement domains and ensuring a blend of sport-related and non-sport-related items. An expert panel and focus group assessed importance and interpretability of each item. During stage II, the FAST was reduced, preserving variance characteristics and factor structure of the beta version and construct validity of the final FAST scale.

RESULTS

During stage I, a 54-item beta version and a separate 9-item pitcher module were developed. During stage II, a 22-item FAST and 9-item pitcher module were finalized. The factor solution for FAST scale items included pain (n = 6), throwing (n = 10), activities of daily living (n = 5), psychological impact (n = 4), and advancement (n = 3). The 6-item pain subscale crossed factors. The remaining subscales and pitcher module are distinctive, correlated, and internally consistent and may be interpreted individually or combined.

CONCLUSION

This article describes the development of the FAST, which assesses clinical outcomes and HRQOL of throwing athletes after UE injury. The FAST encompasses multiple domains of disability and demonstrates excellent construct validity.

CLINICAL RELEVANCE

The FAST provides a single UE region-specific and population-specific PRO scale for high-demand throwers to facilitate measurement of impact of UE injuries on HRQOL and clinical outcomes while quantifying recovery for comparative effectiveness studies.

Chronic ankle instability: Current perspectives

Ankle sprain is reported to be among the most common recurrent injuries. About 20% of acute ankle sprain patients develop chronic ankle instability. The failure of functional rehabilitation after acute ankle sprain leads to the development of chronic ankle instability. Differentiation between functional and anatomical ankle instability is very essential to guide the proper treatment. Stability testing by varus stress test and anterior drawer test should be carried out. Subtalar instability is an important pathology that is commonly by passed during the assessment of chronic ankle instability. Unlike acute ankle sprain, chronic ankle instability might require surgical intervention. The surgical and conservative management options can be very much developed by in-depth knowledge of the ankle anatomy, biomechanics, and pathology. Anatomical repair, augmentation by tendon, or both are the basic methods of surgical intervention. Arthroscopy is becoming more popular in the management of chronic ankle instability.

Patient-Reported Outcomes Measurement Information System Physical Function Item Bank, Version 1.0: Physical Function Assessment for Athletic Patient Populations

CONTEXT

The Patient-Reported Outcomes Measurement Information System (PROMIS) item banks have been validated for general populations, but their application to high-functioning patient populations remains speculative.

OBJECTIVE

To examine the measurement properties of the PROMIS physical function item bank, version 1.0, when applied to individuals representing high levels of physical ability.

DESIGN

Cross-sectional study.

SETTING

National Collegiate Athletic Association Division I and III collegiate athletic training rooms and intramural events.

PATIENTS OR OTHER PARTICIPANTS

A heterogeneous sample of 215 adults from Division I or Division III collegiate or recreational sports volunteered for this study. Participants were divided into 4 groups depending on sport activity and injury status: healthy collegiate (HC; 33 men, 37 women; age = 19.7 ± 1.1 years), injured and currently active in sport (IP; 21 men, 29 women; age = 19.9 ± 1.2 years), injured and currently not active in sport (INP; 12 men, 18 women; age = 19.7 ± 1.3 years), and healthy recreational (HR; 47 men, 18 women; age = 20.1 ± 1.4 years).

MAIN OUTCOME MEASURE(S)

Participants completed 2 assessments: (1) an injury-history questionnaire and (2) the PROMIS physical function item bank, version 1.0, in computer-adaptive form. Mean PROMIS physical function scores were determined for each group.

RESULTS

The PROMIS physical function score for the HC group (61.7 ± 6.0) was higher than for the IP (54.9 ± 7.5) and INP (44.1 ± 8.2) groups (P < .001). The IP group had a higher score than the INP group (P < .001). Mean PROMIS scores were not different between the HC and HR participants (mean difference = 1.9, P = .10).

CONCLUSIONS

The computer-adaptive PROMIS physical function item bank, version 1.0, accurately distinguished injury status in elite-level athletes on a physical function latent trait continuum. Although it was unable to distinguish HC athletes from HR athletes, exposing a possible ceiling effect, it offers potential for use as an outcome instrument for athletic trainers and other sports medicine clinicians.

Rehabilitation for Chronic Ankle Instability With or Without Destabilization Devices: A Randomized Controlled Trial

CONTEXT

Individuals with chronic ankle instability (CAI) have deficits in neuromuscular control and altered movement patterns. Ankle-destabilization devices have been shown to increase lower extremity muscle activity during functional tasks and may be useful tools for improving common deficits and self-reported function.

OBJECTIVE

To determine whether a 4-week rehabilitation program that includes destabilization devices has greater effects on self-reported function, range of motion (ROM), strength, and balance than rehabilitation without devices in patients with CAI.

DESIGN

Randomized controlled clinical trial.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 26 patients with CAI (7 men, 19 women; age = 21.34 ± 3.06 years, height = 168.96 ± 8.77 cm, mass = 70.73 ± 13.86 kg).

INTERVENTION(S)

Patients completed baseline measures and were randomized into no-device and device groups. Both groups completed 4 weeks of supervised, impairment-based progressive rehabilitation with or without devices and then repeated baseline measures.

MAIN OUTCOME MEASURE(S)

We assessed self-reported function using the Foot and Ankle Ability Measure. Ankle ROM was measured with an inclinometer. Ankle strength was assessed using a handheld dynamometer during maximal voluntary isometric contractions. Balance was measured using a composite score of 3 reach directions from the Star Excursion Balance Test and a force plate to calculate center of pressure during eyes-open and eyes-closed single-limb balance. We compared each dependent variable using a 2 × 2 (group × time) analysis of variance and post hoc tests as appropriate and set an a priori α level at .05. The Hedges g effect sizes and associated 95% confidence intervals were calculated.

RESULTS

We observed no differences between the no-device and device groups for any measure. However, both groups had large improvements in self-reported function and ankle strength.

CONCLUSIONS

Incorporating destabilization devices into rehabilitation did not improve ankle function more effectively than traditional rehabilitation tools because both interventions resulted in similar improvements. Impairment-based progressive rehabilitation improved clinical outcomes associated with CAI.