Eric L. Sauers

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.

Patterns of glenohumeral joint laxity and stiffness in healthy men and women.

PURPOSE The purpose of this study was to identify gender-related differences in glenohumeral (GH) joint laxity, stiffness, and generalized joint hypermobility in healthy men and women. METHODS Fifty-one healthy men and women were tested for generalized joint hypermobility, and anterior-posterior (AP) joint laxity and stiffness using a single-group factorial design. RESULTS Women exhibited significantly more anterior joint laxity (men 8.3 +/- 2.2 mm vs women 11.4 +/- 2.8 mm, P < 0.001) and less anterior joint stiffness (men 20.5 +/- 5.0 N x mm(-1) vs women 16.3 +/- 4.2 N x mm(-1), P < 0.01) than men. Men had significantly more posterior joint laxity than anterior (Ant 8.3 +/- 2.2 mm vs Post 9.6 +/- 2.9 mm; P < 0.001), and women also had significantly less anterior joint stiffness than posterior [Ant 16.3 +/- 4.2 N x mm(-1) vs Post 22.1 +/- 6.9 N x mm(-1); P < 0.01], Women also demonstrated significantly more generalized joint hypermobility than men (men 1.0 +/- 1.7 vs women 2.9 +/- 2.1; P = 0.02). CONCLUSIONS Our findings may indicate a possible increased risk for instability in women, especially those participating in sports that require repetitive overhead-throwing motion. Future investigations should seek to determine the contribution of increased GH joint laxity and decreased joint stiffness to various injury states and examine these variables in other populations such as overhead-throwing athletes.

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.

The American Society of Shoulder and Elbow Therapists' Consensus Rehabilitation Guideline for Arthroscopic Anterior Capsulolabral Repair of the Shoulder

SYNOPSIS This manuscript describes the consensus rehabilitation guideline developed by the American Society of Shoulder and Elbow Therapists. The purpose of this guideline is to facilitate clinical decision making during the rehabilitation of patients following arthroscopic anterior capsulolabral repair of the shoulder. This guideline is centered on the principle of the gradual application of stress to the healing capsulolabral repair through appropriate integration of range of motion, strengthening, and shoulder girdle stabilization exercises during rehabilitation and daily activities. Components of this guideline include a 0- to 4-week period of absolute immobilization, a staged recovery of full range of motion over a 3-month period, a strengthening progression beginning at postoperative week 6, and a functional progression for return to athletic or demanding work activities between postoperative months 4 and 6. This document represents the first consensus rehabilitation guideline developed by a multidisciplinary society of international rehabilitation professionals specifically for the postoperative care of patients following arthroscopic anterior capsulolabral repair of the shoulder.

The importance of gender on myokinetic deficits before and after microinjury.

PURPOSE The purpose of this study was to determine the importance of gender on myokinetic deficits before and after muscle microinjury. METHODS A repeated measures design assessed selected muscle force production characteristics in 20 male and 25 female volunteers. Peak force production (PFP) and the peak rate of force production (PRFP) were assessed before and over a 4-d period after an induced muscle microinjury. RESULTS ANOVA revealed statistically significant mean (+/-SD) differences between men and women for PFP and PRFP (P < 0.0001). Both genders demonstrated significant between-day differences for PFP (P < 0.016), whereas only men demonstrated significant between-day differences for PRFP (P < 0.016). CONCLUSIONS Our results reveal that muscle force generating capabilities of physically active men exceed that of women both before and after microinjury. Myokinetic deficits were most pronounced acutely, between 24 and 48 h postinjury, followed by a near complete recovery at day 4 (96 h postinjury). Both genders suffered acute and residual deficits for PFP, whereas only men showed significant acute deficits for PRFP. We recommend that athletes, both male and female, refrain from strenuous exercise at least 48 h postinjury, or until force-generating capabilities normalize. More research needs to be conducted to substantiate these findings.

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

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.

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.