Alison R. Snyder Valier

A unique patient population? Health-related quality of life in adolescent athletes versus general, healthy adolescent individuals.

CONTEXT Normative scores for patient-rated outcome (PRO) instruments are important for providing patient-centered, whole-person care and making informed clinical decisions. Although normative values for the Pediatric Quality of Life Generic Core Scale (PedsQL) have been established in the general, healthy adolescent population, whether adolescent athletes demonstrate similar values is unclear. OBJECTIVE To compare PedsQL scores between adolescent athletes and general, healthy adolescent individuals. DESIGN Cross-sectional study. SETTING Secondary schools. PATIENTS OR OTHER PARTICIPANTS A convenience sample of 2659 interscholastic athletes (males = 2059, females = 600, age = 15.7 ± 1.1 years) represented the athlete group (ATH), and a previously published normative dataset represented the general, healthy adolescent group (GEN). INTERVENTION(S) All participants completed the PedsQL during 1 testing session. MAIN OUTCOME MEASURE(S) The PedsQL consists of 2 summary scores (total, psychosocial) and 4 subscale scores (physical, emotional, social, school), with higher scores indicating better health-related quality of life (HRQOL). Groups were stratified by age (14, 15, or 16 years old). Independent-samples t tests were conducted to compare between-groups and sex differences. RESULTS The ATH group scored higher than the GEN group across all ages for total and psychosocial summary scores and for emotional and social functioning subscale scores (P ≤ .005). For physical functioning, scores of the 15-year-old ATH were higher than for their GEN counterparts (P = .001). Both 14- and 15-year-old ATH scored higher than their GEN counterparts for the school functioning subscale (P ≤ .013), but differences between 16-year olds were not significant (P = .228). Male adolescent athletes reported higher scores than female adolescent athletes across all scores (P ≤ .001) except for social functioning (P = .229). CONCLUSIONS Adolescent athletes reported better HRQOL than GEN, particularly in emotional functioning. These findings further support the notion that ATH constitutes a unique population that requires its own set of normative values for self-reported, patient-rated outcome instruments.

Practice-Based Research Networks, Part II: A Descriptive Analysis of the Athletic Training Practice-Based Research Network in the Secondary School Setting

CONTEXT Analysis of health care service models requires the collection and evaluation of basic practice characterization data. Practice-based research networks (PBRNs) provide a framework for gathering data useful in characterizing clinical practice. OBJECTIVE To describe preliminary secondary school setting practice data from the Athletic Training Practice-Based Research Network (AT-PBRN). DESIGN Descriptive study. SETTING Secondary school athletic training facilities within the AT-PBRN. PATIENTS OR OTHER PARTICIPANTS Clinicians (n = 22) and their patients (n = 2523) from the AT-PBRN. MAIN OUTCOME MEASURE(S) A Web-based survey was used to obtain data on clinical practice site and clinician characteristics. Patient and practice characteristics were obtained via deidentified electronic medical record data collected between September 1, 2009, and April 1, 2011. Descriptive data regarding the clinician and CPS practice characteristics are reported as percentages and frequencies. Descriptive analysis of patient encounters and practice characteristic data was performed, with the percentages and frequencies of the type of injuries recorded at initial evaluation, type of treatment received at initial evaluation, daily treatment, and daily sign-in procedures. RESULTS The AT-PBRN had secondary school sites in 7 states, and most athletic trainers at those sites (78.2%) had less than 5 years of experience. The secondary school sites within the AT-PBRN documented 2523 patients treated across 3140 encounters. Patients most frequently sought care for a current injury (61.3%), followed by preventive services (24.0%), and new injuries (14.7%). The most common diagnoses were ankle sprain/strain (17.9%), hip sprain/strain (12.5%), concussion (12.0%), and knee pain (2.5%). The most frequent procedures were athletic trainer evaluation (53.9%), hot- or cold-pack application (26.0%), strapping (10.3%), and therapeutic exercise (5.7%). The median number of treatments per injury was 3 (interquartile range = 2, 4; range = 2-19). CONCLUSIONS These preliminary data describe services provided by clinicians within the AT-PBRN and demonstrate the usefulness of the PBRN model for obtaining such data.

Injury and Treatment Characteristics of Sport-Specific Injuries Sustained in Interscholastic Athletics: A Report From the Athletic Training Practice-Based Research Network

Background: The inclusion of clinical practice factors, beyond epidemiologic data, may help guide medical coverage and care decisions. Hypothesis: Trends in injury and treatment characteristics of sport-specific injuries sustained by secondary school athletes will differ based on sport. Study Design: Retrospective analysis of electronic patient records. Level of evidence: Level 4. Methods: Participants consisted of 3302 boys and 2293 girls who were diagnosed with a sport-related injury or condition during the study years. Injury (sport, body part, diagnosis via ICD-9 codes) and treatment (type, amount, and duration of care) characteristics were grouped by sport and reported using summary statistics. Results: Most injuries and treatments occurred in football, girls’ soccer, basketball, volleyball, and track and field. Sprain or strain of the ankle, knee, and thigh/hip/groin and concussion were the most commonly documented injuries across sports. The injury pattern for boys’ wrestling differed from other sports and included sprain or strain of the elbow and neck and general medical skin conditions. The most frequently reported service was athletic training evaluation/reevaluation treatment, followed by hot/cold pack, therapeutic exercise, manual therapy techniques, electrical stimulation, and strapping of lower extremity joints. Most sports required 4 to 5 services per injury. With the exception of boys’ soccer and girls’ softball, duration of care ranged from 10 to 14 days. Girls’ soccer and girls’ and boys’ track and field reported the longest durations of care. Conclusion: Injury and treatment characteristics are generally comparable across sports, suggesting that secondary school athletic trainers may diagnose and treat similar injuries regardless of sport. Clinical Relevance: Subtle sport trends, including skin conditions associated with boys’ wrestling and longer duration of care for girls’ soccer, are important to note when discussing appropriate medical coverage and care.

Benefits of and Barriers to Using Patient-Rated Outcome Measures in Athletic Training

CONTEXT Patient-rated outcome measures (PROMs) are important for driving treatment decisions and determining treatment effectiveness. However, athletic trainers (ATs) rarely use them; understanding why may facilitate strategies for collection of these outcomes. OBJECTIVE To identify the benefits of and barriers to using PROMs in athletic training. DESIGN Cross-sectional study. SETTING Web-based survey. PATIENTS OR OTHER PARTICIPANTS A total of 1469 randomly sampled ATs (age = 36.8 ± 9.8 years; 48% female) working in the college/university, 2-year institution, secondary school, clinic, hospital, or industrial/occupational setting. INTERVENTION(S) An e-mail was sent to ATs inviting them to complete a survey regarding the use, benefits, and barriers of PROMs. Athletic trainers who indicated they used PROMs (AT-PRs) completed 65 questions about the benefits of and barriers to their use. Athletic trainers who indicated no use of PROMs (AT-NONs) completed 21 questions about barriers of use. MAIN OUTCOME MEASURE(S) Dependent variables were the endorsements for the benefits of and barriers to the use of PROMs. RESULTS A total of 458 ATs initiated the survey and 421 (AT-PR = 26%, AT-NON = 74%) completed it (response rate = 28.7%). The most frequently endorsed benefits by AT-PRs were enhancing communication with patients (90%) and other health care professionals (80%), directing patient care (87%), and increasing examination efficiency (80%). The most frequently endorsed barriers by AT-PRs were that PROMs are time consuming (44%), difficult (36%), and confusing (31%) for patients and time consuming for clinicians to score and interpret (29%). The most frequently endorsed problems by AT-NONs were that PROMs are time consuming for clinicians to score and interpret (31%), time consuming (46%) and irrelevant to patients (28%), and lacking a support structure for clinicians (29%). CONCLUSIONS These results suggest that, although benefits to using PROMs exist, there are also barriers. Barriers are similar for AT-PRs and AT-NONs. Strategies to decrease barriers and facilitate the use of PROMs warrant investigation.

Scapular Muscle-Activation Ratios in Patients With Shoulder Injuries During Functional Shoulder Exercises

CONTEXT Alterations in scapular muscle activation, which are common with glenohumeral (GH) injuries, affect stability and function. Rehabilitation aims to reestablish activation between muscles for stability by progressing to whole-body movements. OBJECTIVE To determine scapular muscle-activation ratios and individual muscle activity (upper trapezius [UT], middle trapezius [MT], lower trapezius [LT], serratus anterior [SA]) differences between participants with GH injuries and healthy control participants during functional rehabilitation exercises. DESIGN Cross-sectional study. SETTING Laboratory. PATIENTS OR OTHER PARTICIPANTS Thirty-nine participants who had GH injuries (n = 20; age = 23.6 ± 3.2 years, height = 170.7 ± 11.5 cm, mass = 74.7 ± 13.1 kg) or were healthy (n = 19; age = 24.4 ± 3.3 years, height = 173.6 ± 8.6 cm, mass = 74.7 ± 14.8 kg) were tested. INTERVENTION(S) Clinical examination confirmed each participants classification as GH injury or healthy control. Participants performed 4 exercises (bow and arrow, external rotation with scapular squeeze, lawnmower, robbery) over 3 seconds with no load while muscle activity was recorded. MAIN OUTCOME MEASURE(S) We used surface electromyography to measure UT, MT, LT, and SA muscle activity. Scapular muscle-activation ratios (UT:MT, UT:LT, and UT:SA) were calculated (normalized mean electromyography of the UT divided by normalized mean electromyography of the MT, LT, and SA). Exercise × group analyses of variance with repeated measures were conducted. RESULTS No group differences for activation ratios or individual muscle activation amplitude were found (P > .05). Similar UT:MT and UT:LT activation ratios during bow-and-arrow and robbery exercises were seen (P > .05); both had greater activation than external-rotation-with-scapular-squeeze and lawnmower exercises (P < .05). The bow-and-arrow exercise elicited the highest activation from the UT, MT, and LT muscles; SA activation was greatest during the external-rotation-with-scapular-squeeze exercise. CONCLUSIONS Scapular muscle activation was similar between participants with GH injuries and healthy control participants when performing the unloaded multiplanar, multijoint exercises tested. High activation ratios during the bow-and-arrow exercise indicate UT hyperactivity or decreased MT, LT, and SA activity. Our GH injury group may be comparable to high-functioning injured athletes. Study results may assist clinicians in selecting appropriate exercises for scapular muscle activation when caring for injured athletes.

Validity of Single-Item Patient-Rated Outcomes in Adolescent Football Athletes With Concussion

OBJECTIVE To determine the longitudinal and concurrent validity of single-item patient-rated outcomes (PROs) in adolescent football athletes with concussion. DESIGN Longitudinal. SETTING Athletic training facilities. PARTICIPANTS Convenience sample of male adolescent interscholastic athletes (n=94; mean age, 15.7±1.1y; mean grade, 10.1±1.1) from a larger investigation who suffered a sport-related concussion during football and had at least 3 follow-up assessments at 3, 10, and 30 days postinjury (N=249). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Participants were administered 3 global rating questions (1 generic, 1 for daily activities, and 1 for athletic activities) along with the Pediatric Quality of Life Inventory (PedsQL), Multidimensional Fatigue Scale (MFS), and Headache Impact Test-6 (HIT-6) at 3, 10, and 30 days postconcussion. Longitudinal validity was determined through a mixed linear model with random effects for subjects, with pairwise differences assessed using Bonferroni correction (P<.05). Concurrent validity was determined by examining Spearman ρ correlations between the single-item PROs and multi-item PROs. RESULTS All 3 single-item PROs improved over time, demonstrating longitudinal validity (P<.001), except day 10 versus day 30 for global change (P=.072). Fair to moderate correlations were identified between the single-item PROs and the PedsQL, MFS, and HIT-6. CONCLUSIONS The improvement of single-item PRO scores over a postinjury time period of 30 days suggests that these PROs respond as expected to patient recovery. The correlations identified between the single-item PROs and common multi-item PROs used in athletes with concussion demonstrate concurrent validity. Therefore, single-item PROs appear to measure patient progress in adolescent football athletes postconcussion.

Previous Knee Injury and Health-Related Quality of Life in Collegiate Athletes.

CONTEXT   Patient-rated outcome measures (PROMs) capture changes that are important and meaningful to patients, such as health-related quality of life (HRQOL). Although group differences in HRQOL have been reported, little is known about the effect of injury history on HRQOL in collegiate athletes. OBJECTIVE   To determine whether knee-specific function (International Knee Documentation Committee Subjective Knee Evaluation Form [IKDC]) and HRQOL (Short Form 12 [SF-12]) differs in collegiate athletes based on sex and the severity of a previous knee injury. DESIGN   Cross-sectional study. SETTING   Athletic training facilities. PATIENTS OR OTHER PARTICIPANTS   Healthy collegiate athletes (n = 263) were grouped based on self-report of a previous knee injury: severe (n = 47), mild (n = 40), and no (n = 176) knee injury. INTERVENTION(S)   Participants completed the IKDC and SF-12 during their preparticipation examinations. MAIN OUTCOME MEASURE(S)   Generalized linear models were used to assess interactions and main effects of all scores. RESULTS   An interaction effect was observed for the SF-12 role physical subscale (P = .02), with men in the mild- and severe-injury groups reporting worse scores than men with no injury history. We noted a main effect for injury group for the IKDC total score (P < .001) and SF-12 physical functioning (P = .04) and role emotional (P = .04) subscales, with the severe-injury group reporting worse scores than the mild- and no-injury groups. No main effects of sex were reported (P > .05). CONCLUSIONS   Despite returning to full participation, collegiate athletes who previously sustained severe knee injuries tended to report worse knee-specific function and less ability to complete activities due to physical health. In addition, individuals with a history of severe knee injury tended to report more emotional concerns than athletes with a history of mild or no knee injury. Region-specific PROMs may be more sensitive in detecting deficits than generic PROMs after return to full participation. Researchers should investigate the role of PROMs, particularly region-specific PROMs, as potential screening tools for clinical care.

Athletic Training Services During Daily Patient Encounters: A Report From the Athletic Training Practice-Based Research Network

CONTEXT Athletic training services such as taping, wrapping, and stretching are common during routine care but rarely captured in traditional patient documentation. These clinical data are vital when determining appropriate medical coverage and demonstrating the value and worth of athletic trainers (ATs). OBJECTIVE To analyze clinical data from daily encounter forms within the Athletic Training Practice-Based Research Network (AT-PBRN). DESIGN Descriptive study. SETTING Secondary school athletic training clinics. PATIENTS OR OTHER PARTICIPANTS Adolescent patients (n = 4888; age = 16.3 ± 1.4 years) seeking care from ATs. MAIN OUTCOME MEASURE(S) We used Web-based electronic medical records from December 1, 2009, to July 1, 2015, to obtain patient characteristics via deidentified data. Descriptive data regarding practice characteristics from patient encounter forms were analyzed and reported as percentages and frequencies. RESULTS A total of 36 245 patient encounters (mean = 7.5 ± 11.6 encounters per patient) were recorded. Football, basketball, soccer, track, and volleyball accounted for 85.1% of all encounters. Most encounters were for preventive services (48.8%, n = 22 329), followed by care for a current injury (37.2%, n = 17 027) and care for a new injury (13.9%, n = 6368). Of the preventive encounters, taping (52.7%) was the most common service provided, followed by ice- or hot-pack application (25.4%) and treatment (9.6%). Taping (28.7%) was also the most common service for current injuries, followed by treatment (26.7%) and ice- or hot-pack application (26.2%). CONCLUSIONS Our findings highlight the unique role of ATs as health care providers who provide substantial preventive services to their patients. Further, these results represent one of the first attempts to describe athletic training services related to nontime-loss injuries, emphasizing the significant role that ATs play in the health care of secondary school athletes. These findings should help clinicians and administrators make more informed decisions regarding appropriate medical coverage.

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.

The Functional Arm Scale for Throwers (FAST)—Part II: Reliability and Validity of an Upper Extremity Region-Specific and Population-Specific Patient-Reported Outcome Scale for Throwing Athletes:

Background: The Functional Arm Scale for Throwers (FAST) is an upper extremity (UE) region-specific and population-specific patient-reported outcome (PRO) scale developed to measure health-related quality of life in throwers with UE injuries. Stages I and II, described in a companion paper, of FAST development produced a 22-item scale and a 9-item pitcher module. Stage III of scale development, establishing reliability and validity of the FAST, is reported herein. Purpose: To describe stage III of scale development: reliability and validity of the FAST. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Data from throwing athletes collected over 5 studies were pooled to assess reliability and validity of the FAST. Reliability was estimated using FAST scores from 162 throwing athletes who were injured (n = 23) and uninjured (n = 139). Concurrent validity was estimated using FAST scores and Disabilities of the Arm, Shoulder, and Hand (DASH) and Kerlan-Jobe Orthopaedic Clinic (KJOC) scores from 106 healthy, uninjured throwing athletes. Known-groups validity was estimated using FAST scores from 557 throwing athletes who were injured (n = 142) and uninjured (n = 415). Reliability and validity were assessed using intraclass correlation coefficients (ICCs), and measurement error was assessed using standard error of measurement (SEM) and minimum detectable change (MDC). Receiver operating characteristic curves and sensitivity/specificity values were estimated for known-groups validity. Data from a separate group (n = 18) of postsurgical and nonoperative/conservative rehabilitation patients were analyzed to report responsiveness of the FAST. Results: The FAST total, subscales, and pitcher module scores demonstrated excellent test-retest reliability (ICC, 0.91-0.98). The SEM95 and MDC95 for the FAST total score were 3.8 and 10.5 points, respectively. The SEM95 and MDC95 for the pitcher module score were 5.7 and 15.7 points, respectively. The FAST scores showed acceptable correlation with DASH (ICC, 0.49-0.82) and KJOC (ICC, 0.62-0.81) scores. The FAST total score classified 85.1% of players into the correct injury group. For predicting UE injury status, a FAST total cutoff score of 10.0 out of 100.0 was 91% sensitive and 75% specific, and a pitcher module score of 10.0 out of 100.0 was 87% sensitive and 78% specific. The FAST total score demonstrated responsiveness on several indices between intake and discharge time points. Conclusion: The FAST is a reliable, valid, and responsive UE region-specific and population-specific PRO scale for measuring patient-reported health care outcomes in throwing athletes with injury.