Luzita I. Vela

The Disablement in the Physically Active Scale, Part II: The Psychometric Properties of an Outcomes Scale for Musculoskeletal Injuries

CONTEXT Outcomes assessment is an integral part of ensuring quality in athletic training, but few generic instruments have been specifically designed to measure disablement in the physically active. OBJECTIVE To assess the psychometric properties of the Disablement in the Physically Active Scale (DPA), a patient-report, generic outcomes instrument. DESIGN Observational study. SETTING We collected data in 5 settings with competitive and recreational athletes. Participants entered into the study at 3 distinct points: (1) when healthy and (2) after an acute injury, or (3) after a persistent injury. PATIENTS OR OTHER PARTICIPANTS Measures were obtained from 368 baseline participants (202 females, 166 males; age  =  20.1 ± 3.8 years), 54 persistent participants (32 females, 22 males; age  =  22.0 ± 8.3 years), and 28 acutely injured participants (8 females, 20 males; age  =  19.8 ± 1.90 years). MAIN OUTCOME MEASURE(S) We assessed internal consistency with a Cronbach α and test-retest reliability with intraclass correlation (2,1) values. The scales factor structure was assessed with a hierarchical confirmatory factor analysis. Concurrent validity was assessed with a Pearson correlation. Responsiveness was calculated using a receiver operating characteristic curve and a minimal clinically important difference value. RESULTS The Cronbach α scores for the DPA were 0.908 and 0.890 in acute and persistent groups, respectively. The intraclass correlation (2,1) value of the DPA was 0.943 (95% confidence interval  =  0.885, 0.972). The fit indices values were 1.89, 0.852, 0.924, 0.937, and 0.085 (90% confidence interval  =  0.066, 0.103) for the minimum sample discrepancy divided by degrees of freedom, goodness-of-fit index, Tucker-Lewis Index, comparative fit index, and root mean square error of approximation, respectively. The DPA scores accounted for 51% to 56.4% of the variation in global functioning scores. The area under the curve was statistically significant, and the minimally clinically important difference values were established. CONCLUSIONS The DPA is a reliable, valid, and responsive instrument.

Evidence-Based Sports Medicine: Outcomes Instruments for Active Populations

Clear and directed outcomes assessment is an integral part of clinical decision making. For sports medicine clinicians, it is crucial to choose appropriate instruments that are grounded in disablement theory, designed to measure the ability of a physically active population, and have established psychometric properties. Although there is no instrument ideal for every situation in sports medicine, there are important guidelines that a clinician can follow that will allow for the selection of an appropriate instrument. The purposes of this article are to (1) introduce the reader to self-report instruments available, with particular attention to those most appropriate for athletic populations, (2) describe the relationship between disablement paradigms and health-related self-report instruments, and (3) describe the process of instrument development.

Transient Disablement in the Physically Active With Musculoskeletal Injuries, Part I: A Descriptive Model

CONTEXT Disablement theory has been characterized as the sequence of events that occurs after an injury, but little research has been conducted to establish how disablement is experienced and described by physically active persons. OBJECTIVE To describe the disablement process in physically active persons with musculoskeletal injuries. DESIGN Concurrent, embedded mixed-methods study. For the qualitative portion, interviews were conducted to create descriptive disablement themes. For the quantitative portion, frequencies analysis was used to identify common terminology. SETTING National Collegiate Athletic Association Division I collegiate and club sports, collegiate intramural program, large high school athletics program, and outpatient orthopaedic center. PATIENTS OR OTHER PARTICIPANTS Thirty-one physically active volunteers (15 males, 16 females; mean age  =  21.2 years; range, 14-53 years) with a current injury (18 lower extremity injuries, 13 upper extremity injuries) participated in individual interviews. Six physically active volunteers (3 males, 3 females; mean age  =  22.2 years; range, 16-28 years) participated in the group interview to assess trustworthiness. DATA COLLECTION AND ANALYSIS We analyzed interviews through a constant-comparison method, and data were collected until saturation occurred. Common limitations were transformed into descriptive themes and were confirmed during the group interview. Disablement descriptors were identified with frequencies and fit to the themes. RESULTS A total of 15 overall descriptive themes emerged within the 4 disablement components, and descriptive terms were identified for each theme. Impairments were marked by 4 complaints: pain, decreased motion, decreased muscle function, and instability. Functional limitations were denoted by problems with skill performance, daily actions, maintaining positions, fitness, and changing directions. Disability consisted of problems with participation in desired activities. Lastly, problems in quality of life encompassed uncertainty and fear, stress and pressure, mood and frustration, overall energy, and altered relationships. A preliminary generic outcomes instrument was generated from the findings. CONCLUSIONS Our results will help clinicians understand how disablement is described by the physically active. The findings also have implications for how disablement outcomes are measured.

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.

A learner-centered technique and clinical reasoning, reflection, and case presentation attributes in athletic training students.

CONTEXT Providing opportunities to develop clinical decision-making skills, including clinical reasoning, is an important aspect of clinical education. The learner-centered technique of summarizing the history and findings, narrowing the differential, analyzing the differential, probing the instructor about uncertainties, plan management, and selecting an issue for self-directed study (SNAPPS) is used in medicine to express clinical reasoning. OBJECTIVE To investigate the effects of SNAPPS on the clinical reasoning, reflection, and 4 case presentation attributes (length, conciseness, case summary, and expression of clinical reasoning) in athletic training students. DESIGN Randomized controlled clinical trial. SETTING Three undergraduate programs accredited by the Commission on Accreditation of Athletic Training Education. PATIENTS OR OTHER PARTICIPANTS We randomly assigned 38 athletic training students (17 men, 21 women; age = 21.53 ± 1.18 years, grade point average = 3.25 ± 0.31) who had completed at least 1 year of clinical education and all orthopaedic evaluation coursework to the SNAPPS group or the usual and customary group using a stratification scheme. INTERVENTION(S) The SNAPPS group completed four 45-minute clinical reasoning and case presentation learning modules led by an investigator to learn the SNAPPS technique, whereas the usual and customary group received no formal instruction. Both groups audio recorded all injury evaluations performed over a 2-week period. MAIN OUTCOME MEASURES Participants completed the Diagnostic Thinking Inventory and Reflection in Learning Scale twice. Case presentations were analyzed for 4 attributes: length, conciseness, case summary, and expression of clinical reasoning. RESULTS Case presentations were longer (t18.806 = -5.862, P < .001) but were more concise (t32 = 11.297, P < .001) for the SNAPPS group than for the usual and customary group. The SNAPPS group performed better on both the case summary subscale (t32 = 2.857, P = .007) and the clinical reasoning subscale (t25.773 = -14.162, P < .001) than the other group. We found a time effect for Diagnostic Thinking Inventory scores (F1,34 = 6.230, P = .02) but observed no group effects (F1,34 = 0.698, P = .41) or time-by-group interaction (F1,34 = 1.050, P = .31). The Reflection in Learning Scale scores analysis revealed no group-by-time interaction (F1,34 = 1.470, P = .23) and no group (F1,34 = 3.751, P = .06) or time (F1,34 = 0.835, P = .37) effects. CONCLUSIONS The SNAPPS is an effective and feasible clinical education technique for case presentations. This learner-centered technique provides the opportunity for the expression of clinical reasoning skills.

Resistance Training for Shoulder Complex Stabilization

The purpose of this review is to provide resistance training recommendations to improve shoulder joint stabilization based on shoulder mechanics and mechanisms of injury. The shoulder encounters external axial loading and internal forces from the shoulder musculature that can lead to injury with shoulder stabilization weakness. Training the musculature to stabilize the shoulder increases the likelihood of achieving muscle balance and reducing the risk of injury. The selected exercises and exercise prescriptions are recommended to create this balance to prevent shoulder impingement and injury caused by common axial loading.