Health-related quality of life as a primary clinical outcome in sport rehabilitation.

Health-related quality of life (HRQOL) is a broad, multidimensional concept that refers to a synthesis of several health domains including the physical, psychological, and social domains, all of which are affected by individual experiences, expectations, beliefs, and perceptions. HRQOL also shares a well-established connection with contemporary disablement models, which enhances its utility for identifying individual experience, expectations, and values, which can also influence the way a person views his or her health status. However, the routine evaluation of HRQOL in clinical research and patient care in the field of sport rehabilitation remains limited. HRQOL has implications for both athletes who suffer sport-related injury (SRI) and those who care for them. The purpose of this article is to help clinicians and researchers understand HRQOL as a primary outcome in sport rehabilitation. First, the article provides a definition of HRQOL and explains its relationship to contemporary disablement models. Next, research demonstrating that HRQOL is sensitive to both athletic participation and to SRI in athletes at both secondary school and college levels is reviewed. Finally, several important clinical tools that can be used to measure HRQOL by both clinicians and clinical researchers are presented. Criteria to be used in selecting these tools are also presented.

Upper extremity injury history, current pain rating, and health-related quality of life in female softball pitchers.

CONTEXT: Throwing-related arm injuries are common in softball pitchers and may lead to diminished health-related quality of life (HRQOL). Arm symptoms such as pain have been reported to be more common in healthy overhead athletes than nonoverhead athletes. Furthermore, more frequent shoulder symptoms and lower shoulder function have been demonstrated in athletes with self-reported history of shoulder injury. OBJECTIVE: To evaluate the relationship between arm injury history, current pain rating, and HRQOL assessed via 2 region-specific patient self-report scales in high school and college softball pitchers. DESIGN: Cross-sectional. SETTING: High school and college athletic training facilities. PARTICIPANTS: 25 female softball pitchers (10 high school, 15 college; 18 ± 2 y, 169 ± 7.6 cm, 67.5 ± 10.3 kg). INTERVENTION: Self-reported arm injury history and rating of current pain and HRQOL were collected during the late season. MAIN OUTCOME MEASURES: A self-report questionnaire of arm injury history and current pain rating was used, and HRQOL was assessed via 2 region-specific scales: the Disabilities of the Arm, Shoulder, and Hand (DASH) and the Functional Arm Scale for Throwers© (FAST©). Correlational analysis was used to evaluate the relationships between arm injury history, current pain rating, and the DASH total score and sport module and the FAST total score, pitching module, and subscales. RESULTS: A history of arm injury from throwing was reported by 64% of participants, 31% of whom had to cease activity for more than 10 d. The most common site of arm time-loss injury was the shoulder (81%). Mild to severe shoulder pain during the competitive season was reported by 60% of respondents. The DASH and the FAST total scores were significantly correlated (r = .79, P < .001). Respondent rating of shoulder pain correlated significantly with the DASH total (r = .69) and sports module (r = .69) and the FAST total (r = .71), pitching module (r = .65), and pain (r = .73), impairment (r = .76), functional-limitation (r = .79), disability (r = .52), and societal-limitations (r = .46) subscales. CONCLUSION: History of arm injury is common in female high school and college softball pitchers. Severe injury and elevated pain are associated with lower HRQOL that extends beyond the playing field.

Responsiveness of the numeric pain rating scale in patients with shoulder pain and the effect of surgical status.

CONTEXT: The Numeric Pain Rating Scale (NPRS) is commonly used to assess pain. Change in the NPRS across time can be interpreted with responsiveness indices. OBJECTIVE: To determine the minimal clinically important difference (MCID) of the NPRS. DESIGN: Single-group repeated measures. SETTING: Outpatient rehabilitation clinics. PATIENTS: Patients with shoulder pain (N = 136). MAIN OUTCOME MEASURES: At the initial evaluation patients completed the Penn Shoulder Score (PSS), which includes pain, satisfaction, and function sections. Pain was measured using an 11-point NPRS for 3 conditions of pain: at rest, with normal daily activities, and with strenuous activities. The NPRS average was calculated by averaging the NPRS scores for 3 conditions of pain. The final PSS was completed after 3-4 wk of rehabilitation. To determine the MCID for the NPRS average, the minimal detectible change of 8.6 points for the PSS function scale (0-60 points) was used as an external criterion anchor to classify patients as meaningfully improved (≥8.6 point change) or not improved (<8.6-point change). The MCID for the NPRS average was also determined for subgroups of surgical and nonsurgical patients. Cohen's effect sizes were calculated as a measure of group responsiveness for the NPRS average. RESULTS: Using a receiver-operating-characteristic analysis, the MCID for the average NPRS for all patients was 2.17, and it was 2.17 for both the surgical and nonsurgical subgroup: area-under-the-curve range .74-.76 (95%CI: .55-.95). The effect size for all patients was 1.84, and it was 1.51 and 1.94 for the surgical and nonsurgical groups, respectively. CONCLUSIONS: The NPRS average of 3 pain questions demonstrated responsiveness with an MCID of 2.17 in patients with shoulder pain receiving rehabilitation for 3-4 wk. The effect sizes indicated a large effect. However, responsiveness values are not static. Further research is indicated to assess responsiveness of the NPRS average in different types of patients with shoulder pain.

Measurement properties of headache-specific outcomes scales in adolescent athletes.

CONTEXT: Recurrent headaches significantly affect health-related quality of life (HRQOL) in adults; the impact of headache on HRQOL among adolescents is unknown, and the psychometric properties of headache-specific outcomes instruments have not been adequately studied in this population. OBJECTIVE: To evaluate the psychometric properties of the Headache Impact Test (HIT-6) and Pediatric Migraine Disability Assessment (PedMIDAS) in healthy adolescent athletes. DESIGN: Descriptive survey. SETTING: High school athletic training facilities during the fall sports season. PARTICIPANTS: 177 high school athletes (89 males and 88 females). INTERVENTIONS: A survey consisting of a demographic and concussion-history questionnaire, a graded symptom scale, the HIT-6, and the PedMIDAS. Internal consistency (α), test-retest reliability (r(s)), Bland-Altman analyses, and the Mann-Whitney U test were used to evaluate psychometric properties and age and gender differences. MAIN OUTCOME MEASURES: The HIT-6 and PedMIDAS item and total scores. RESULTS: Test-retest reliability for the HIT-6 total score was r(s) = .72, and reliability of individual items ranged from r(s) = .52 to .67. The test-retest reliability for the PedMIDAS total score was r(s) = .61, and reliability of individual items ranged from r(s) = .23 to .62. Both scales demonstrated acceptable internal consistency: HIT-6 α = .89-.90 and PedMIDAS α = .71-.75. CONCLUSIONS: The authors found moderate test-retest reliability for the HIT-6 and the PedMIDAS in a healthy adolescent athlete population. Research on the applicability and utility of the HIT-6 and PedMIDAS in concussed adolescents is warranted.

The influence of high-voltage electrical stimulation on edema formation after acute injury: a systematic review.

CONTEXT: Electrical stimulation is often used to control edema formation after acute injury. However, it is unknown whether its theoretical benefits translate to benefits in clinical practice. OBJECTIVES: To systematically review the basic-science literature regarding the effects of high-voltage pulsed stimulation (HVPS) for edema control. EVIDENCE ACQUISITION: CINAHL (1982 to February 2010), PubMed (1966 to February 2010), Medline (1966 to February 2010), and SPORTDiscus (1980 to February 2010) databases were searched for relevant studies using the following keywords: edema, electrical stimulation, high-volt electrical stimulation, and combinations of these terms. Reference sections of relevant studies were hand-searched. Included studies investigated HVPS and its effect on acute edema formation and included outcome measures specific to edema. Eleven studies met the inclusion criteria. Methodological quality and level of evidence were assessed for each included study. Effect sizes were calculated for primary edema outcomes. EVIDENCE SYNTHESIS: Studies were critiqued by electrical stimulation treatment parameters: mode of stimulation, polarity, frequency, duration of treatment, voltage, intensity, number of treatments, and overall time of treatments. The available evidence indicates that HVPS administered using negative polarity, pulse frequency of 120 pulses/s, and intensity of 90% visual motor contraction may be effective at curbing edema formation. In addition, the evidence suggests that treatment should be administered in either four 30-min treatment sessions (30-min treatment, 30-min rest cycle for 4 h) or a single, continuous180-min session to achieve the edema-suppressing effects. CONCLUSIONS: These findings suggest that the basic-science literature provides a general list of treatment parameters that have been shown to successfully manage the formation of edema after acute injury in animal subjects. These treatment parameters may facilitate future research related to the effects of HVPS on edema formation in humans and guide practical clinical use.

Health-related quality of life differs between adolescent athletes and adolescent nonathletes.

CONTEXT: Patient-oriented outcome measures such as the Medical Outcomes Short Form (SF-36) and the Pediatric Outcomes Data Collection Instrument (PODCI) are important tools for determining the impact of events like sport-related injury on health-related quality of life (HRQoL). Unfortunately, there are no published studies using these instruments that compare adolescent athletes with their nonathlete peers, making interpretations of these measures in this population difficult. OBJECTIVE: To compare HRQoL in adolescent athletes and nonathletes using 2 common instruments. DESIGN: Cross-sectional. SETTING: 7 high schools. PARTICIPANTS: 219 athletes and 106 nonathletes. INTERVENTION: None. MAIN OUTCOME MEASURES: The SF-36 and the PODCI were completed in a counterbalanced manner during 1 session. Dependent variables included the 8 subscale and 2 composite scores of the SF-36 and the 5 subscale scores and 1 global score of the PODCI. RESULTS: On the SF-36, athletes reported higher scores on the physical function, general health, social functioning, and mental health subscales and the mental composite score and lower scores on the bodily pain subscale than nonathletes. On the PODCI, athletes reported higher scores on the sport and physical function and happiness subscales and lower scores on the pain/comfort subscale. CONCLUSIONS: Athletes reported higher scores on a number of SF-36 and PODCI subscales related to mental, emotional, and physical well-being than nonathletes. Our findings suggest that athletic involvement may be a benefit to the overall health status of adolescents and imply that athletes may be a distinct adolescent group requiring their own normative values when using the SF-36 and PODCI.

Impact of Prior Concussions on Health-Related Quality of Life in Collegiate Athletes.

OBJECTIVE: To investigate how self-reported sport-related concussion history affects health-related quality of life in collegiate athletes. DESIGN: Cross sectional. SETTING: Division I university, Division II university, and a junior college. PARTICIPANTS: Three hundred two collegiate athletes (210 men, 92 women). ASSESSMENT OF RISK FACTORS: Participants completed a demographic information sheet and concussion history form; they were then grouped by number of previous self-reported concussions, designated as 0, 1-2, or 3+. MAIN OUTCOME MEASURES: The Medical Outcomes Short Form (SF-36) and the Headache Impact Test (HIT-6). RESULTS: Significant differences between groups were found for the bodily pain, vitality, and social functioning subscales of the SF-36. The 3+ group had significantly lower scores for bodily pain (48.1 ± 8.9) compared with the 1-2 group (P = 0.028, 52.1 ± 7.7) and 0 group (P < 0.01, 53.5 ± 8.3), for vitality (52.4 ± 8.4) compared with the 0 group (P = 0.011, 55.9 ± 8.6), and for social functioning (48.5 ± 9.4) compared with the 1-2 group (P = 0.028, 51.6 ± 7.3) and 0 group (P = 0.003, 51.9 ± 8.1). Significant differences were noted on the HIT-6 total score. The 3+ group reported greater impact of headache (46.7 ± 6.4) than the 1-2 group (P = 0.05, 44.6 ± 6.4) and 0 group (P < 0.001, 42.9 ± 5.8). The 1-2 group also had higher HIT-6 scores than the 0 group (P = 0.033). CONCLUSIONS: Results suggest that a collegiate athlete's perception of bodily pain, vitality, social functioning, and headache is adversely affected by previous sport-related concussions. However, by incorporating general and specific outcome measures into the standard evaluation of sport-related concussion, the clinician can better determine how the athlete is responding to treatment and recovery.

Impact of prior concussions on health-related quality of life in collegiate athletes.

OBJECTIVE: To investigate how self-reported sport-related concussion history affects health-related quality of life in collegiate athletes. DESIGN: Cross sectional. SETTING: Division I university, Division II university, and a junior college. PARTICIPANTS: : Three hundred two collegiate athletes (210 men, 92 women). ASSESSMENT OF RISK FACTORS: Participants completed a demographic information sheet and concussion history form; they were then grouped by number of previous self-reported concussions, designated as 0, 1-2, or 3+. MAIN OUTCOME MEASURES: The Medical Outcomes Short Form (SF-36) and the Headache Impact Test (HIT-6). RESULTS: Significant differences between groups were found for the bodily pain, vitality, and social functioning subscales of the SF-36. The 3+ group had significantly lower scores for bodily pain (48.1 +/- 8.9) compared with the 1-2 group (P = 0.028, 52.1 +/- 7.7) and 0 group (P < 0.01, 53.5 +/- 8.3), for vitality (52.4 +/- 8.4) compared with the 0 group (P = 0.011, 55.9 +/- 8.6), and for social functioning (48.5 +/- 9.4) compared with the 1-2 group (P = 0.028, 51.6 +/- 7.3) and 0 group (P = 0.003, 51.9 +/- 8.1). Significant differences were noted on the HIT-6 total score. The 3+ group reported greater impact of headache (46.7 +/- 6.4) than the 1-2 group (P = 0.05, 44.6 +/- 6.4) and 0 group (P < 0.001, 42.9 +/- 5.8). The 1-2 group also had higher HIT-6 scores than the 0 group (P = 0.033). CONCLUSIONS: Results suggest that a collegiate athlete's perception of bodily pain, vitality, social functioning, and headache is adversely affected by previous sport-related concussions. However, by incorporating general and specific outcome measures into the standard evaluation of sport-related concussion, the clinician can better determine how the athlete is responding to treatment and recovery.

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.

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 person's 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 patient's 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.

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.