Differences in health-related quality of life among patients after ankle injury.

Ankle sprains are the most common injuries sustained in the physically active, often associated with pain and functional limitations long after initial recovery. In recent years, the impact of ankle sprains on general health and health-related quality of life (HRQoL) has been noted in athletes, but is not well-documented in the general population. We examined differences in HRQoL and general health between individuals with ankle sprain history and healthy controls. Those with ankle sprain reported significantly higher body mass index and general body pain, and lower SF-8 physical component scores than healthy controls. Additionally, there is some indication that physical activity is lower in those with ankle sprain history. This is an important step in illustrating the adverse sequelae of ankle sprains on population health and HRQoL.

Knee Surgery Is Associated With Greater Odds of Knee Osteoarthritis Diagnosis.

CONTEXT: Knee osteoarthritis (OA) frequently develops following knee injury/surgery. It is accepted that knee injury/surgery precipitates OA with previous studies examining this link in terms of years after injury/surgery. However, postinjury OA prevalence has not been examined by decade of life; thereby, limiting our understanding of the age at which patients are diagnosed with posttraumatic knee OA. OBJECTIVE: Evaluate the association between the knee injury and/or surgical history, present age, and history of receiving a diagnosis of knee OA. DESIGN: Cross-sectional survey. SETTING: Online survey. PARTICIPANTS: A total of 3660 adults were recruited through ResearchMatch©. Of these, 1723 (47.1%) were included for analysis due to history of (1) knee surgery (SURG: n = 276; age = 53.8 [15.3] y; and body mass index [BMI] = 29.9 [8.0] kg/m2), (2) nonsurgical knee injury (INJ: n = 449; age = 46.0 [15.6] y; and BMI = 27.5 [6.9] kg/m2), or (3) no knee injury (CTRL: n = 998; age = 44.0 [25.2] y; and BMI = 26.9 [6.6] kg/m2). Respondents were subdivided by decade of life (20-29 through 70+). INTERVENTION: An electronic survey regarding knee injury history, treatment, and diagnosis of knee OA. MAIN OUTCOME MEASURES: Binary logistic regression determined the association between knee surgical status and OA by decade of life. Participants with no histories of OA or lower-extremity injury were the referent categories. BMI was a covariate in all analyses. RESULTS: SURG respondents were more likely to report having knee OA than CTRL for all age groups (odds ratios: 11.43-53.03; P < .001). INJ respondents aged 30 years and older were more likely to have OA than CTRL (odds ratios: 2.99-14.22; P < .04). BMI influenced associations for respondents in their 50s (P = .001) and 60s (P < .001) only. CONCLUSIONS: INJ increased the odds of reporting a physician diagnosis of knee OA in adults as young as 30 to 39 years. Importantly, SURG yielded 3 to 4 times greater odds of being diagnosed with knee OA compared with INJ in adults as young as 20 to 29 years. Delaying disease onset in these young adults is imperative to optimize the quality of life long term after surgery.

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.

Clinical assessment of low-back-pain treatment outcomes in athletes.

PATIENT SCENARIO: A 21-year-old male rodeo athlete complains of acute low back pain (LBP) after a bareback event. The athlete wishes to compete in a rodeo event in 4 d. CLINICAL OUTCOMES ASSESSMENT: Given the questionable validity and reliability of traditional clinical examination techniques for LBP, a treatment subgroup classification system combined with clinical outcomes assessment provides greater insight into suitable clinical interventions and patient response to treatment. Four LBP treatment subgroups based on the patient's clinical presentation and symptoms have been established: manipulation, stabilization, specific exercise, and traction. Manipulation subgroup research has produced a valid clinical prediction rule (CPR). The Visual Analog Scale, Numeric Rating Scale (NRS), Oswestry Low Back Pain Disability Index (ODI), Roland Morris Disability Questionnaire, Short Form 36 (SF-36), and Global Rating of Change Scale are valid, reliable, and responsive outcomes instruments with established values for minimum clinically important difference (MCID). These instruments document important changes in disablement and health-related quality of life in patients with low back injury, as well as demonstrate treatment outcomes. CLINICAL DECISION MAKING: On examination the athlete presents with moderate pain and disability as measured by the NRS, ODI, and SF-36 and meets all 5 criteria for the manipulation subgroup, indicating a high likelihood of success with manipulative therapy when following the guidelines presented in the CPR. Expected outcomes values, based on MCID values, were met after 1 treatment. Preferred outcomes, based on physical activity requirements for sport, were met on day 4. CLINICAL BOTTOM LINE: LBP generators are difficult to establish using traditional clinical examination techniques. The combined use of clinical criteria, using an LBP subgroup system, and baseline outcomes measures should guide treatment. Benchmarks should be guided by established MCID values for each instrument.

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.

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 scale's 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.

Prophylactic Ankle Taping and Bracing: A Numbers-Needed-to-Treat and Cost-Benefit Analysis.

OBJECTIVE: Taping and bracing are thought to decrease the incidence of ankle sprains; however, few investigators have addressed the effect of preventive measures on the rate of ankle sprains. Our purpose was to examine the effectiveness of ankle taping and bracing in reducing ankle sprains by applying a numbers-needed-to-treat (NNT) analysis to previously published studies. DATA SOURCES: We searched PubMed, CINAHL, SPORT Discus, and PEDro for original research from 1966 to 2002 with key words ankle taping, ankle sprains, injury incidence, prevention, ankle bracing, ankle prophylaxis, andnumbers needed to treat. We eliminated articles that did not address the effects of ankle taping or bracing on ankle injury rates using an experimental design. DATA SYNTHESIS: The search produced 8 articles, of which 3 permitted calculation of NNT, which addresses the clinical usefulness of an intervention by providing estimates of the number of treatments needed to prevent 1 injury occurrence. In a study of collegiate intramural basketball players, the prevention of 1 ankle sprain required the taping of 26 athletes with a history of ankle sprain and 143 without a prior history. In a military academy intramural basketball program, prevention of 1 sprain required bracing of 18 athletes with a history of ankle sprain and 39 athletes with no history. A study of ankle bracing in competitive soccer players produced an NNT of 5 athletes with a history of previous sprain and 57 without a prior injury. A cost- benefit analysis of ankle taping versus bracing revealed taping to be approximately 3 times more expensive than bracing. CONCLUSIONS/RECOMMENDATIONS: Greater benefit is achieved in applying prophylactic ankle taping or bracing to athletes with a history of ankle sprain, compared with those without previous sprains. The generalizability of these results to other physically active populations is unknown.