Alison R. Snyder

Manual Therapy, Exercise, and Traction for Patients With Cervical Radiculopathy: A Randomized Clinical Trial

Background: To date, optimal strategies for the management of patients with cervical radiculopathy remain elusive. Preliminary evidence suggests that a multimodal treatment program consisting of manual therapy, exercise, and cervical traction may result in positive outcomes for patients with cervical radiculopathy. However, limited evidence exists to support the use of mechanical cervical traction in patients with cervical radiculopathy. Objective: The purpose of this study was to examine the effects of manual therapy and exercise, with or without the addition of cervical traction, on pain, function, and disability in patients with cervical radiculopathy. Design: This study was a multicenter randomized clinical trial. Setting: The study was conducted in orthopedic physical therapy clinics. Patients: Patients diagnosed with cervical radiculopathy (N=81) were randomly assigned to 1 of 2 groups: a group that received manual therapy, exercise, and intermittent cervical traction (MTEXTraction group) and a group that received manual therapy, exercise, and sham intermittent cervical traction (MTEX group). Intervention: Patients were treated, on average, 2 times per week for an average of 4.2 weeks. Measurements: Outcome measurements were collected at baseline and at 2 weeks and 4 weeks using the Numeric Pain Rating Scale (NPRS), the Patient-Specific Functional Scale (PSFS), and the Neck Disability Index (NDI). Results: There were no significant differences between the groups for any of the primary or secondary outcome measures at 2 weeks or 4 weeks. The effect size between groups for each of the primary outcomes was small (NDI=1.5, 95% confidence interval [CI]=−6.8 to 3.8; PSFS=0.29, 95% CI=−1.8 to 1.2; and NPRS=0.52, 95% CI=−1.8 to 1.2). Limitations: The use of a nonvalidated clinical prediction rule to diagnose cervical radiculopathy and the lack of a control group without treatment were limitations of this study. Conclusions: The results suggest that the addition of mechanical cervical traction to a multimodal treatment program of manual therapy and exercise yields no significant additional benefit to pain, function, or disability in patients with cervical radiculopathy.

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

OBJECTIVE To present and discuss disablement models and the benefits of using these models as a framework to assess clinical outcomes in athletic training. BACKGROUND Conceptual schemes that form the basic architecture for clinical practice, scholarly activities, and health care policy, disablement models have been in use by health care professions since the 1960s. Disablement models are also the foundation for clinical outcomes assessment. Clinical outcomes assessment serves as the measurement tool for patient-oriented evidence and is a necessary component for evidence-based practice. DESCRIPTION Disablement models provide benefits to health professions through organization of clinical practice and research activities; creation of a common language among health care professionals; facilitation of the delivery of patient-centered, whole-person health care; and justification of interventions based on a comprehensive assessment of the effect of illness or injury on a persons overall health-related quality of life. Currently, the predominant conceptual frameworks of disability in health care are those of the National Center for Medical Rehabilitation Research and the World Health Organization. Disablement models need to be understood, used, and studied by certified athletic trainers to promote patient-centered care and clinical outcomes assessment for the development of evidence-based practice in athletic training. CLINICAL AND RESEARCH ADVANTAGES: For clinicians and researchers to determine effective athletic training treatments, prevention programs, and practices, they must understand what is important to patients by collecting patient-oriented evidence. Patient-oriented evidence is the most essential form of outcomes evidence and necessitates an appreciation of all dimensions of health, as outlined by disablement models. The use of disablement models will allow the athletic training profession to communicate, measure, and prioritize the health care needs of patients, which will facilitate organized efforts aimed at assessing the quality of athletic training services and practices and ultimately promote successful evidence-based athletic training practice.

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

OBJECTIVE To provide an overview of clinical outcomes assessment, discuss the classification of outcomes measures, present considerations for choosing outcomes scales, identify the importance of assessing clinical outcomes, and describe the critical link between the utilization of disablement models and clinical outcomes assessment. BACKGROUND Clinical outcomes are the end result of health care services. Clinical outcomes assessment is based on the conceptual framework of disablement models and serves as the measurement method for the collection of patient-oriented evidence, a concept central to evidence-based practice. DESCRIPTION Clinical outcomes management refers to the use of outcomes measures in the course of routine clinical care and provides athletic trainers with a mechanism to assess treatment progress and to measure the end results of the services they provide. Outcomes measures can be classified as either clinician based or patient based. Clinician-based measures, such as range of motion and strength, are taken directly by clinicians. Patient-based measures solicit a patients perception as to health status in the form of questionnaires and survey scales. Clinician-based measures may assist with patient evaluation, but patient-based measures should always be included in clinical assessment to identify what is important to the patient. CLINICAL AND RESEARCH ADVANTAGES: Evidence-based athletic training practice depends on clinical outcomes research to provide the foundation of patient-oriented evidence. The widespread use of clinical outcomes assessment, based on the disablement model framework, will be necessary for athletic trainers to demonstrate the effectiveness of therapies and interventions, the provision of patient-centered care, and the development of evidence-based practice guidelines.

Recent Injury and Health-Related Quality of Life in Adolescent Athletes

CONTEXT Health-related quality of life (HRQOL) is a global concept that takes into account the physical, psychological, and social domains of health. Determining the extent to which injury affects HRQOL is an important aspect of rehabilitation practice, enabling comparisons of clinical outcomes across different conditions in diverse patient groups. OBJECTIVE To examine the extent to which a self-reported recent injury affected HRQOL in adolescent athletes using 2 generic patient self-report scales. DESIGN Cross-sectional study. SETTING High school classrooms and athletic training facilities. PATIENTS OR OTHER PARTICIPANTS A convenience sample of uninjured (n = 160) and injured (n = 45) adolescent athletes. INTERVENTION(S) THE INDEPENDENT VARIABLE WAS INJURY STATUS: uninjured versus injured. All participants completed a self-administered brief health status questionnaire and the Short Form-36 Health Survey Questionnaire (SF-36) and Pediatric Outcomes Data Collection Instrument (PODCI) in a counterbalanced manner. MAIN OUTCOME MEASURE(S) Dependent variables included 8 subscale and 2 composite scores of the SF-36 and 5 subscale scores and 1 global score of the PODCI. Group differences were assessed with the Mann-Whitney U test (P < or = .05) and reported as median and interquartile range. RESULTS On the SF-36, the injured group demonstrated lower scores (P < .008) for physical functioning, limitations due to physical health problems, bodily pain, social functioning, and the physical composite. On the PODCI, the injured group reported lower scores (P < .01) on the pain and comfort subscale and the global score. CONCLUSIONS Adolescent athletes with self-reported injuries demonstrated lower HRQOL than their uninjured peers. As expected, recent injury affected physical functioning and pain. Social functioning (on the SF-36) and global HRQOL (on the PODCI) also decreased, suggesting that injuries affected areas beyond the expected physical component of health. Clinicians need to recognize the full spectrum of negative influences that injuries may have on HRQOL in adolescent athletes.

Evaluation of Health-Related Quality of Life in Patients with Shoulder Pain: Are We Doing the Best We Can?

This article provides an understanding of patient-based shoulder outcome tools and the conceptual framework of disablement models from which the patient-based outcome tools are based. To allow for the evaluation of function, disability, and health-related quality of life in patients suffering from shoulder pain and in particular those whose shoulders have high physical demands, the use of shoulder self-report patient-oriented outcome tools must become standard of practice. A wide variety of available outcome tools demonstrate acceptable levels of measurement properties and are appropriate for virtually every patient with a shoulder disorder.

Change Is Hard: Adopting a Disablement Model for Athletic Training

We have heard skepticism from both our researcher and clinician colleagues about the value of and need for clinical outcomes assessment and evidence-based practice (EBP). Some clinicians think a move toward outcomes assessment and EBP is an admission that the current care provided by athletic trainers (ATs) is inadequate. Furthermore, some clinicians are naturally nervous that conducting outcomes research is too time consuming to be practical, too complicated to be done correctly, or both. Additionally, some scholars minimize the importance of both outcomes assessment and EBP by claiming they are just another form of research design or methods, no more or less important than any other form of research. We directly challenge all these notions and suggest that the benefits to both patient care and the standing of the athletic training profession that flow from engagement in clinical outcomes assessment and EBP by both clinicians and researchers far outweigh the concerns identified previously. Ongoing improvement of patient care must be a central focus of all health professions and is a continuous effort toward a goal that is never truly achieved in an absolute sense. Suggesting that clinical outcomes assessment is no more or less important than other forms of research