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Ryan S. McCann, Kyle B. Kosik, Masafumi Terada, and Phillip A. Gribble

- and patient-oriented outcomes were not predictive of recurrent ankle sprains. High school student-athletes in the United States sustain over 326,000 ankle injuries annually, 1 80% of which are ankle sprains. 2 Athletes competing in National Collegiate Athletic Association (NCAA) sports account for

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Alison R. Snyder, Jessica C. Martinez, R. Curtis Bay, John T. Parsons, Eric L. Sauers, and Tamara C. Valovich McLeod

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.

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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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Nicole L. Cosby and Jay Hertel

Patient Scenario:

A 20-y-old male Division 1 college basketball player sustained a grade 2 inversion ankle sprain during preseason that is preventing him from practicing and competing.

Clinical Outcomes Assessment:

The Foot and Ankle Ability Measure (FAAM) was administered to the injured athlete as an evaluative tool to provide the clinician with valuable subjective information on the patient’s self-reported function. The FAAM consists of 2 subscales: the activities of daily living (ADL) subscale and the sports subscale. Together the 2 subscales contain 29 questions (21 questions on the ADL and 8 on the sports subscale), which assess self-reported function and disability in the foot and ankle.

Clinical Decision Making:

The addition of the self-reported functional measures provides the clinician with more quantitative data to make clinical decisions than is possible with typical clinical exams. Self-reported functional assessments should not replace thorough clinical examination or sound clinical judgment; instead they should be an adjunct to them.

Clinical Bottom Line:

In addition to our objective assessment tools, the FAAM provides clinicians with a tool that can be used to assess function and disability through our patients’ self-reported responses. When used for evaluative purposes the FAAM can measure an individual’s changes in function and disability over time.

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Matthew Burwell, Justin DiSanti, and Tamara C. Valovich McLeod

Clinical Scenario: Youth athletes may specialize in a sport of their choosing, or based on external pressures, to pursue elite status in that sport. Current evidence shows an association between highly specialized athletes and an increase in injuries as well as a connection between injury and lower health-related quality of life (HRQOL). Clinical Question: In college athletes, do early sport specialization characteristics (ie, age at specialization and degree of specialization) impact current HRQOL? Summary of Key Findings: The literature was searched for studies that investigated the age of specialization (early vs late) or degree of specialization (high, moderate, and low) and the impact on HRQOL. (1) The search returned 6 possible studies related to the clinical question. Three of the studies met the inclusion criteria and were used for this appraisal. (2) Two of the 3 included studies reported that highly specialized athletes noted lower HRQOL. (3) One study found there to be no significant difference in HRQOL between athletes who specialized early versus late but did find those who specialized early to have a greater incidence of injuries that required surgery. Clinical Bottom Line: There is moderate evidence that early sport specialization is associated with lower HRQOL compared with late sport specialization. It is important to educate athletes, parents, and coaches on the potential detriments that are associated with early sport specialization to allow stakeholders to make informed decisions regarding participation. Strength of Recommendation : Grade B evidence exists to support the idea that early, intensive sport specialization may be associated with decreased HRQOL in current college athletes.

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Jennifer M. Medina McKeon and Kathleen E. Yancosek

Context:

There are discrepancies regarding the efficacy of neural gliding exercises for the management of carpal tunnel syndrome (CTS).

Objective:

To conduct a systematic review assessing the efficacy of neural gliding in comparison to alternative nonsurgical treatment for the management of CTS.

Evidence Acquisition:

A computerized search was performed in April 2008. Criteria for inclusion required that studies (1) were written in English, (2) examined the efficacy of neural gliding techniques for treatment of CTS, and (3) included at least one of the selected patient-oriented outcomes. Effect sizes, relative risk, and 95% confidence intervals were calculated to compare neural gliding to alternative treatment.

Evidence Synthesis:

Six studies met inclusion criteria. For all variables, none were consistently favorable toward neural gliding over alternative treatment. However, comparisons across studies revealed a possible trend toward improved outcomes with the use neural gliding.

Conclusions:

The efficacy of neural gliding is not clear. More research is necessary to determine the population that may respond optimally to this treatment.

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Tamara C. Valovich McLeod and Johna K. Register-Mihalik

Patient Scenario:

An adolescent female youth soccer athlete, with a previous concussion history, suffered a second concussion 4 wk ago. Her postconcussive symptoms are affecting her school performance and social and family life.

Clinical Outcomes Assessment:

Concussion is typically evaluated via symptoms, cognition, and balance. There is no specific patient-oriented outcomes measure for concussion. Clinicians can choose from a variety of generic and specific outcomes instruments aimed at assessing general health-related quality of life or various concussion symptoms and comorbidities such as headache, migraine, fatigue, mood disturbances, depression, anxiety, and concussion-related symptoms.

Clinical Decision Making:

The data obtained from patient self-report instruments may not actively help clinicians make return-to-play decisions; however, these scales may be useful in providing information that may help the athlete return to school, work, and social activities. The instruments may also serve to identify issues that may lead to problems down the road, including depression or anxiety, or serve to further explore the nature of an athlete’s symptoms.

Clinical Bottom Line:

Concussion results in numerous symptoms that have the potential to linger and has been associated with depression and anxiety. The use of outcomes scales to assess health-related quality of life and the effect of other symptoms that present with a concussion may allow clinicians to better evaluate the effects of concussion on physical, cognitive, emotional, social, school, and family issues, leading to better and more complete management.

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Brandy J. Mailer, Tamara C. Valovich McLeod, and R. Curtis Bay

Context:

Clinicians often rely on the self-report symptoms of patients in making clinical decisions; hence it is important that these scales be reliable.

Objective:

To determine the test-retest reliability of healthy youth in completing a graded symptom scale (GSS), modified from the Head Injury Scale Self-Report Concussion Symptoms Scale (HIS).

Design:

Repeated-measures.

Setting:

Middle school classroom.

Patients or Other Participants:

126 middle school students.

Intervention:

A survey consisting of a demographic and life events questionnaire and a GSS asking about symptom severity and duration.

Main Outcomes Measures:

Score for each symptom on the severity and duration scale and a total symptom score (TSS) and the total number of symptoms endorsed (TSE) from the severity scale. Responses on a life events questionnaire were also recorded.

Results:

We found excellent reliability for TSS (ICC = .93) and TSE (ICC = .88) for the severity scale. We found moderate to excellent reliability on the individual symptoms of both the severity (ICC = .65-.89) and duration (ICC =.56-.96) scales.

Conclusions:

Healthy youth can reliably self-report symptoms using a GSS. This patient-oriented outcome measure should be incorporated into more investigations in this age group.

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Cynthia J. Wright, Shelley W. Linens, and Mary S. Cain

Context:

There is minimal patient-oriented evidence regarding the effectiveness of interventions targeted to reduce symptoms associated with chronic ankle instability (CAI). In addition, clinicians aiming to prioritize care by implementing only the most effective components of a rehabilitative program have very little evidence on comparative efficacy.

Objective:

To assess the comparative efficacy of 2 common ankle rehabilitation techniques (wobble-board [WB] balance training and ankle strengthening using resistance tubing [RT]) using patient-oriented outcomes.

Design:

Randomized controlled trial.

Setting:

Laboratory.

Patients:

40 patients with CAI randomized into 2 treatment groups: RT and WB. CAI inclusion criteria included a history of an ankle sprain, recurrent “giving way,” and a Cumberland Ankle Instability Tool (CAIT) score ≤25.

Interventions:

Participants completed 5 clinician-oriented tests (foot-lift test, time-in-balance, Star Excursion Balance Test, figure-of-8 hop, and side-hop) and 5 patient-oriented questionnaires (CAIT, Foot and Ankle Ability Measure [FAAM], Activities of Daily Living [ADL] and FAAM Sport scale, Short-Form 36 [SF-36], and Global Rating of Function [GRF]). After baseline testing, participants completed 12 sessions over 4 wk of graduated WB or RT exercise, then repeated baseline tests.

Main Outcome Measures:

For each patient- and clinician-oriented test, separate 2 × 2 RMANOVAs analyzed differences between groups over time (alpha set at P = .05).

Results:

There was a significant interaction between group and time for the FAAM-ADL (P = .04). Specifically, the WB group improved postintervention (P < .001) whereas the RT group remained the same (P = .29). There were no other significant interactions or significant differences between groups (all P > .05). There were significant improvements postintervention for the CAIT, FAAM-Sport, GRF, SF-36, and all 5 clinician-oriented tests (all P < .001).

Conclusions:

A single-exercise 4-wk intervention can improve patient- and clinician-oriented outcomes in individuals with CAI. Limited evidence indicates that WB training was more effective than RT.

Level of Evidence:

Therapy, level 1b.

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Robert J. Bonser, Bethany L. Hansberger, Rick A. Loutsch, Christy L. Gendron, and Russell T. Baker

physical) of LAS on society. Therefore, the purpose of this critically appraised topic (CAT) was to assess the efficacy of the Mulligan Concept™ posterior fibular MWM technique for patients with acute LAS as measured using patient-oriented outcomes and time to discharge. Focused Clinical Question What are