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.
John T. Parsons and Alison R. Snyder
Samuel J. Cervantes and Alison R. Snyder
Lori A. Michener, Alison R. Snyder and Brian G. Leggin
The Numeric Pain Rating Scale (NPRS) is commonly used to assess pain. Change in the NPRS across time can be interpreted with responsiveness indices.
To determine the minimal clinically important difference (MCID) of the NPRS.
Single-group repeated measures.
Outpatient rehabilitation clinics.
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.
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.
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.
Sarah K. Piebes, Alison R. Snyder, R. Curtis Bay and Tamara C. Valovich McLeod
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.
To evaluate the psychometric properties of the Headache Impact Test (HIT-6) and Pediatric Migraine Disability Assessment (PedMIDAS) in healthy adolescent athletes.
High school athletic training facilities during the fall sports season.
177 high school athletes (89 males and 88 females).
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.
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.
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.
Eric L. Sauers, Danelle L. Dykstra, R. Curtis Bay, Kellie Huxel Bliven and Alison R. Snyder
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.
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.
High school and college athletic training facilities.
25 female softball pitchers (10 high school, 15 college; 18 ± 2 y, 169 ± 7.6 cm, 67.5 ± 10.3 kg).
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.
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.
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.
Alison R. Snyder, April L. Perotti, Kenneth C. Lam and R. Curtis Bay
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.
To systematically review the basic-science literature regarding the effects of high-voltage pulsed stimulation (HVPS) for edema control.
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.
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 edemasuppressing effects.
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.
Alison R. Snyder and Kenneth C. Lam
Edited by John Parsons
Eric L. Sauers and Alison R. Snyder
Ashley N. Marshall, Alison R. Snyder Valier, Aubrey Yanda and Kenneth C. Lam
Context: There has been an increased interest in understanding how ankle injuries impact patient outcomes; however, it is unknown how the severity of a previous ankle injury influences health-related quality of life (HRQOL). Objective: To determine the impact of a previous ankle injury on current HRQOL in college athletes. Design: Cross-sectional study. Setting: Athletic training clinics. Participants: A total of 270 participants were grouped by the severity of a previous ankle injury (severe = 62, mild = 65, and no injury = 143). Main Outcome Measures: Participants completed the Foot and Ankle Ability Measure (FAAM) and the Short Form 12 (SF-12). Methods: A 2-way analysis of variance with 2 factors (injury group and sex) was used to identify interaction and main effects for the FAAM and SF-12. Results: No interactions were identified between injury group and sex. Significant main effects were observed for injury group, where the severe injury group scored lower than athletes with mild and no injuries on the FAAM activities of daily living, FAAM Global, and SF-12 mental health subscale scores. In addition, a main effect was present for sex in the SF-12 general health, social functioning, and mental health subscales in which females reported significantly lower scores than males. Conclusions: Our findings suggest that a severe ankle injury impacts HRQOL, even after returning back to full participation. In addition, females tended to report lower scores than males for aspects of the SF-12, suggesting that sex should be considered when evaluating HRQOL postinjury. As a result, clinicians should consider asking athletes about their previous injury history, including how much time was lost due to the injury, and should mindful of returning athletes to play before they are physiologically and psychologically ready, as there could be long-term negative effects on the patients’ region-specific function as well as aspects of their HRQOL.