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Johanna M. Hoch and Carl G. Mattacola

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Cameron J. Powden, Matthew C. Hoch and Johanna M. Hoch

Context: There is an increased emphasis on the need to capture and incorporate self-reported function to make clinical decisions when providing patient-centered care. Response shift (RS), or a change in an individual’s self-evaluation of a construct, may affect the accurate assessment of change in self-reported function throughout the course of rehabilitation. A systematic review of this phenomenon may provide valuable information regarding the accuracy of self-reported function. Objectives: To systematically locate and synthesize the existing evidence regarding RS during care for various orthopedic conditions. Evidence Acquisition: Electronic databases (PubMed, MEDLINE, CINAHL, SPORTDiscus, and Psychology & Behavioral Sciences Collection) were searched from inception to November 2016. Two investigators independently assessed methodological quality using the modified Downs and Black Quality Index. The quality of evidence was assessed using the Strength-of-Recommendation Taxonomy. The magnitude of RS was examined through effect sizes. Evidence Synthesis: Nine studies were included (7 high quality and 2 low quality) with a median Downs and Black Quality Index score of 81.25% (range = 56.25%–93.75%). Overall, the studies demonstrated weak to strong effect sizes (range = −1.58–0.33), indicating the potential for RS. Of the 36 point estimates calculated, 22 (61.11%), 2 (5.56%), and 12 (33.33%) were associated with weak, moderate negative, and strong negative effect sizes, respectively. Conclusions: There is grade B evidence that a weak RS, in which individuals initially underestimate their disability, may occur in people undergoing rehabilitation for an orthopedic condition. It is important for clinicians to be aware of the potential shift in their patients’ internal standards, as it can affect the evaluation of health-related quality of life changes during the care of orthopedic conditions. A shift in the internal standards of the patient can lead to subsequent misclassification of health-related quality of life changes that can adversely affect clinical decision making.

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Megan N. Houston, Johanna M. Hoch and Matthew C. Hoch

Context: Postinjury, college athletes have reported elevated levels of fear. However, it is unclear how a history of ankle sprain impacts injury-related fear. Objective: The aim of this study was to determine if Fear-Avoidance Beliefs Questionnaire (FABQ) scores differ between college athletes with a history of a single ankle sprain, those with recurrent ankle sprains, and healthy controls. Design: Cross-sectional design. Setting: National Collegiate Athletic Association institutions. Patients: From a large database of college athletes, 75 participants with a history of a single ankle sprain, 44 with a history of recurrent ankle sprains (≥2), and 28 controls with no injury history were included. Main Outcome Measures: Participants completed an injury history questionnaire and the FABQ. On the injury history form, the participants were asked to indicate if they had ever sustained an ankle sprain and, if yes, to describe how many. FABQ scores ranged from 0 to 66 with higher scores representing greater fear. Results: Athletes with a history of recurrent ankle sprains (median, 28.00; interquartile range, 18.25–38.00) reported higher levels of fear than those with a history of a single ankle sprain (21.00; 8.00–31.00; P = .03; effect size = 0.199) and healthy controls (5.50; 0.00–25.00; P < .001; effect size = 0.431). Athletes with a history of a single sprain reported greater fear than healthy controls (P = .01, effect size = 0.267). Athletes with a history of a single sprain reported greater fear than healthy controls (P = .02, effect size = 0.23). Conclusions: College athletes with a history of ankle sprain exhibited greater levels of fear on the FABQ than healthy controls. These findings suggest that ankle sprains in general may increase injury-related fear and that those with a history of recurrent sprains are more vulnerable.

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Caitlin Brinkman, Shelby E. Baez, Francesca Genoese and Johanna M. Hoch

Clinical Scenario: Patients after sports-related injury experience deficits in self-efficacy. Goal setting may be an appropriate psychoeducation technique to enhance self-efficacy after sports-related injury. Clinical Question: Does goal setting–enhanced rehabilitation improve self-efficacy compared with traditional rehabilitation alone in individuals with sports-related injury? Summary of Key Findings: Two randomized controlled trials were included. The two studies selected assessed changes in self-efficacy before and after a goal-setting intervention following sports-related injury in an athletic population. Both studies used the Sports Injury Rehabilitation Beliefs Survey to evaluate self-efficacy. Clinical Bottom Line: There is currently consistent, good-quality, patient-oriented evidence that supports the use of goal setting to improve self-efficacy in patients undergoing rehabilitation for sports-related injury compared with the standard of care group. Future research should examine optimal timing for the implementation of goal setting in order to enhance self-efficacy following sports-related injury. Strength of Recommendation: The grade of A is recommended by the Strength of Recommendation Taxonomy for consistent, good-quality, patient-oriented evidence.

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Matthew C. Hoch, Lauren A. Welsch, Emily M. Hartley, Cameron J. Powden and Johanna M. Hoch

Context: The Y-Balance Test (YBT) is a dynamic balance assessment used as a preseason musculoskeletal screen to determine injury risk. While the YBT has demonstrated excellent test-retest reliability, it is unknown if YBT performance changes following participation in a competitive athletic season. Objective: Determine if a competitive athletic season affects YBT performance in field hockey players. Design: Pretest-posttest. Setting: Laboratory. Participants: 20 NCAA Division I women's field hockey players (age = 19.55 ± 1.30 y; height = 165.10 ± 5.277 cm; mass = 62.62 ± 4.64 kg) from a single team volunteered. Participants had to be free from injury throughout the entire study and participate in all athletic activities. Interventions: Participants completed data collection sessions prior to (preseason) and following the athletic season (postseason). Between data collections, participants competed in the fall competitive field hockey season, which was ~3 months in duration. During data collection, participants completed the YBT bilaterally. Main Outcome Measures: The independent variable was time (preseason, postseason) and the dependent variables were normalized reach distances (anterior, posteromedial, posterolateral, composite) and between-limb symmetry for each reach direction. Differences between preseason and postseason were examined using paired t tests (P ≤ .05) as well as Bland-Altman limits of agreement. Results: 4 players sustained a lower extremity injury during the season and were excluded from analysis. There were no significant differences between preseason and postseason reach distances for any reach directions on either limb (P ≥ .31) or in the between-limb symmetries (P ≥ .52). The limits of agreement analyses determined there was a low mean bias across measurements (≤1.67%); however, the 95% confidence intervals indicated there was high variability within the posterior reach directions over time (±4.75 to ± 14.83%). Conclusion: No changes in YBT performance were identified following a competitive field hockey season in Division I female athletes. However, the variability within the posterior reach directions over time may contribute to the limited use of these directions for injury risk stratification.

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Johanna M. Hoch, Jamie L. Legner, Christina Lorete and Matthew C. Hoch

Context: Documented barriers to implementation of patient-reported outcome instruments (PROs) in practice include administration and scoring time. The Quick Foot and Ankle Ability Measure (Quick-FAAM) was developed to decrease these barriers; however, the clinometric properties in an acute population are unknown. Purpose: To determine the internal consistency, validity, and the floor and ceiling effects of the Quick-FAAM in patients seeking treatment for an acute or subacute ankle or foot health condition. Study Design: Cross-Sectional. Setting: Healthcare facilities.Patients: 50 patients (20.3 ± 2.2 y, 177.9 ± 10.7 cm, 80 ± 19.4 kg) seeking treatment for an acute or subacute ankle or foot condition. Main Outcome Measures: Each patient completed a demographic and health-history questionnaire followed by 5 PROs: the Quick-FAAM, the FAAM-Activities of Daily Living (ADL), FAAM-Sport, the modified Disablement in the Physically Active Scale (mDPA), the Short-Form 12 (SF-12) and the PROMISv1.2 Physical Function (PROMIS-PF). Cronbach alpha was used to determine internal consistency and Spearman’s rank correlations were performed to examine the relationship between the Quick-FAAM and all other outcomes. Results: The Quick-FAAM was very strongly correlated with the FAAM-Total (r = .91, r 2 = .83, P < .001), FAAM-ADL (r = .83, r 2 = .69, P < .001), FAAM-Sport (r = .89, r 2 = .79, P < .001), SF12-Physical Component Score (PCS, r = .74, r 2 = .55, P < .001), mDPA-PCS (r = -.83, r 2 = .69, P < .001) and PROMIS PF (r = .85, r 2 = .72, P < .001). There was a weak or no relationship with the SF12-Mental Component Score (MCS, r = .04, r 2 = .00, P < .001) and the mDPA-MCS (r = -.35, r 2 = .12, P < .001). A total of 8% (n = 4) of the patients scored a 0, and 2% (n = 1) patients scored a 48. Conclusion: The Quick-FAAM demonstrated good convergent and divergent validity along with good internal consistency. There was no evidence of a floor or ceiling effect. Therefore, the Quick-FAAM should be considered for use in practice when determining treatment effectiveness for patients with acute or subacute ankle or foot health conditions. Future research should determine the test-retest reliability and the minimal detectable change of this instrument.

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Johanna M. Hoch, Megan N. Houston, Shelby E. Baez and Matthew C. Hoch

Context: Many athletes return to sport after anterior cruciate ligament reconstruction (ACLR) with lingering physical or mental health impairments. Examining health-related quality of life (HRQL) and fear-avoidance beliefs across the spectrum of noninjured athletes and athletes with a history of ACLR may provide further insight into targeted therapies warranted for this population. Objective: The purpose of this study was to examine differences in fear-avoidance beliefs and HRQL in college athletes with a history of ACLR not participating in sport (ACLR-NPS), participating in sport (ACLR-PS), and healthy controls (Control) with no history of injury participating in sport. Design: Cross-sectional. Setting: Laboratory. Patients (or Other Participants): A total of 10 college athletes per group (ACLR-NPS, ACLR-PS, and Control) were included. Participants were included if on a roster of a Division I or III athletic team during data collection. Interventions: Participants completed a demographic survey, the modified Disablement in the Physically Active Scale (mDPA) to assess HRQL, and Fear-Avoidance Beliefs Questionnaire (FABQ) to assess fear-avoidance beliefs. Main Outcome Measures: Scores on the mDPA (Physical and Mental) and FABQ subscales (Sport and Physical Activity) were calculated, a 1-way Kruskal–Wallis test and separate Mann–Whitney U post hoc tests were performed (P < .05). Results: ACLR-NPS (30.00 [26.00]) had higher FABQ-Sport scores than ACLR-PS (18.00 [26.00]; P < .001) and Controls (0.00 [2.50]; P < .001). ACLR-NPS (21.50 [6.25]) had higher FABQ-Physical Activity scores than ACLR-PS (12.50 [13.00]; P = .001) and Controls (0.00 [1.00]; P < .001). Interestingly, ACLR-PS scores for FABQ-Sport (P = .01) and FABQ-Physical Activity (P = .04) were elevated compared with Controls. ACLR-NPS had higher scores on the mDPA-Physical compared with the ACLR-PS (P < .001) and Controls (P < .001), and mDPA-Mental compared with ACLR-PS (P = .01), indicating decreased HRQL. Conclusions: The ACLR-NPS had greater fear-avoidance beliefs and lower HRQL compared with ACLR-PS and Controls. However, the ACLR-PS had higher scores for both FABQ subscales compared with Controls. These findings support the need for additional psychosocial therapies to address fear-avoidance beliefs in the returned to sport population.

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Megan N. Houston, Johanna M. Hoch, Bonnie L. Van Lunen and Matthew C. Hoch

Context:

Health-related quality of life (HRQOL) is a broad term for the impact of injury or illness on physical, psychological, and social health dimensions. Injury has been associated with decreased HRQOL in athletes. However, the influence of injury history, participation status, time since last injury, and injury severity on HRQOL remains unclear.

Objective:

To compare HRQOL in collegiate athletes based on injury history, participation status, time since last injury, and injury severity and to examine relationships between HRQOL outcomes.

Design:

Cross-sectional.

Setting:

3 National Collegiate Athletic Association (NCAA) institutions.

Participants:

467 collegiate athletes (199 males, 268 females; 19.5 ± 1.3 y, 173.9 ± 10.5 cm, 71.9 ± 13.6 kg) were recruited from NCAA Division I (n = 299) and Division III (n = 168) institutions. Athletes were included regardless of participation status, which created a diverse sample of current and past injury histories.

Main Outcome Measures:

During a single session, participants completed an injury history form, the Disablement in the Physically Active Scale (DPA), and the Fear-Avoidance Beliefs Questionnaire (FABQ). Dependent variables included DPA-Physical Summary Component (DPA-PSC), DPA-Mental Summary Component (DPA-MSC), and FABQ Scores.

Results:

HRQOL differences were detected between groups based on injury history, participation status, and time since last injury. No differences were detected for injury severity. A moderate correlation was identified between the DPA-PSC and FABQ (rs = 0.503, P < .001) and a weak relationship was identified between the DPA-MSC and FABQ (rs = 0.266, P < .001).

Conclusions:

Injury negatively influenced HRQOL in athletes with a current injury. While those individuals participating injured reported better HRQOL than the athletes sidelined due to injury, deficits were still present and should be monitored to ensure a complete recovery. Identifying the patient’s perception of impairment will help facilitate evidencebased treatment and rehabilitation strategies that target the physical and psychosocial aspects of health.

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Johanna M. Hoch, Shelby E. Baez, Robert J. Cramer and Matthew C. Hoch

Context: The modified Disablement in the Physically Active scale (mDPA) has become a commonly utilized patient-reported outcome instrument for physically active patients. However, the factor structure of this instrument has not been verified in individuals with chronic ankle instability (CAI). Furthermore, additional evidence examining the mDPA in individuals with CAI is warranted. Objective: The purpose of this study was to verify the factor structure of the mDPA and compare the physical summary component (PSC) and mental summary component (MSC) in those with and without CAI. Design: Cross-sectional. Setting: Laboratory. Participants: A total of 118 CAI and 81 healthy controls from a convenience sample participated. Intervention: Not applicable. Main Outcome Measures: All subjects completed the 16-item mDPA that included the PSC and MSC; higher scores represent greater disablement. To examine the model fit of the mDPA, a single-factor and 2-factor (PSC and MSC) structures were tested. Group differences were examined with independent t tests (P ≤ .05) and Hedges’ g effect sizes (ESs). Results: Model fit indices showed the 2-factor structure to possess adequate fit to the data, χ 2(101) = 275.58, P < .001, comparative-fit index = .91, root mean square error of approximation = .09 (95% confidence interval [CI], .08–.11), and standardized root mean square residual = .06. All items loaded significantly and in expected directions on respective subscales (λ range = .59–.87, all Ps < .001). The CAI group reported greater disablement as indicated from PSC (CAI: 11.45 [8.30] and healthy: 0.62 [1.80], P < .001, ES = 1.67; 95% CI, 1.33–1.99) and MSC (CAI: 1.75 [2.58] and healthy: 0.58 [1.46], P < .001, ES = 0.53; 95% CI, 0.24–0.82) scores. Conclusions: The 2-factor structure of the mDPA was verified. Individuals with CAI reported greater disablement on the PSC compared with healthy controls. The moderate ES on the MSC between groups warrants further investigation. Overall, these results indicate the mDPA is a generic patient-reported outcome instrument that can be utilized with individuals who have CAI.

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Francesca Genoese, Shelby E. Baez, Nicholas Heebner, Matthew C. Hoch and Johanna M. Hoch

Context: Deficits in reaction time, decreased self-reported knee function, and elevated levels of injury-related fear have been observed in individuals who sustain anterior cruciate ligament injury. Understanding the relationship between these variables may provide the impetus to further investigate effective intervention strategies to address these deficits in individuals after anterior cruciate ligament reconstruction (ACLR). Objective: To examine the relationship between injury-related fear and lower-extremity visuomotor reaction time (VMRT) in individuals with a history of ACLR. A secondary purpose was to determine the relationship between self-reported knee function and lower-extremity VMRT in individuals with a history of ACLR. Design: Cross-sectional study. Setting: Laboratory. Participants: Twenty participants between the ages of 18–35 years, with history of unilateral ACLR within the last 10 years, who injured their knee playing or training for organized or recreational sports. Main Outcome Measures: Scores on the athlete fear avoidance questionnaire, the fear-avoidance beliefs questionnaire (FABQ), the knee injury and osteoarthritis outcome score, and reaction time (in seconds) on the lower-extremity VMRT task using the FitLight Trainer, bilaterally. Spearman Rho correlations examined the relationship between the dependent variables. Results: There was a moderate positive correlation between VMRT and FABQ-total (r = .62, P < .01), FABQ-sport (r = .56, P = .01), and FABQ-physical activity (r = .64, P < .01) for the injured limb. Correlations between FABQ scores and VMRT for the uninjured limb were weak positive correlations (r = .36–.41, P > .05). Weak correlations between the osteoarthritis outcome score subscales, athlete fear avoidance questionnaire, and VMRT were observed for the injured limb (P > .05). Conclusions: Individuals with a history of ACLR who exhibited elevated levels of injury-related fear demonstrated slower VMRT. There were no relationships between self-reported knee function and VMRT. Future research should explore interventions to address injury-related fear and VMRT in individuals after ACLR.