Health-Related Quality of Life in Physically Active Individuals with a History of Injury

Individuals around the globe engage in physical activity for personal interest or general health and fitness. Although participation in regular physical activity is important for general health it also brings with it the risk of injury. Ankle sprains, anterior cruciate ligament tears, and concussions are just a few of the injuries sustained by physically active individuals with long-term implications. With the number of physically active individuals on the rise, sports-related injuries are of growing concern. Health-related quality of life (HRQOL) is a personal evaluation of everyday functioning and well-being. A variety of injuries and health conditions associated with physical activity have been linked to HRQOL deficits. Despite these findings, the literature has yet to determine the influence of injury in physically active populations on the multidimensional profile of HRQOL. The purpose of this dissertation was to explore the influence of injury history of HRQOL in physically active individuals. The purpose of the literature review was to systematically summarize the extent to which HRQOL deficits are present in individuals with chronic ankle instability (CAI) and adolescent and collegiate athletes. The purposes of these studies were to explore HRQOL differences between individuals with and without CAI, to determine if clinical and laboratory measure of function can predict HRQOL scores in individuals with CAI, and to examine the scale structure of the Disablement in the Physically Active Scale (DAP), as well as, the influence of injury and participation on HRQOL in collegiate athletes. The results of the systematic reviews suggest that CAI and sports-related injuries are associated with decreased HRQOL. In Project I, individuals with CIA displayed decreased HRQOL based on generic, region-specific, and dimension—specific patient-reported outcomes. In Project II, a combination of mechanical and functional impairments accounted for 17-36% of the variance associated with patient-outcomes related to physical function and fear. In Project III, collegiate athletes exhibited HRQOL deficits based on injury history, participation status, and time since last injury. Additionally, physical and mental subscales were identified within the existing structure of the DPA. The results of these studies expose the overlap between physical impairment and patient-reported outcomes and confirm that physically active individuals exhibit HRQOL deficits following injury. As a result, patient-reported outcomes should be used in clinical practice to treat the entire spectrum of disability

Health-Related Quality of Life in Athletes: A Systematic Review With Meta-Analysis

Context: Assessment of health-related quality of life (HRQOL) after injury is important. Differences in HRQOL between nonathletes and athletes and between injured and uninjured athletes have been demonstrated; however, the evidence has not been synthesized. Objective: To answer the following questions: (1) Does HRQOL differ among adolescent and collegiate athletes and nonathletes? (2) Does HRQOL differ between injured adolescent and collegiate athletes or between athletes with a history of injury and uninjured athletes or those without a history of injury? Data Sources: We systematically searched CINAHL, MEDLINE, SPORTDiscus, and PubMed. A hand search of references was also conducted. Study Selection: Studies were included if they used generic instruments to compare HRQOL outcomes between athletes and nonathletes and between uninjured and injured athletes. Studies were excluded if they did not use a generic instrument, pertained to instrument development, or included retired athletes or athletes with a chronic disease. Data Extraction: We assessed study quality using the modified Downs and Black Index Tool. Bias-corrected Hedges g effect sizes and 95% confidence intervals (CIs) were calculated. The Strength of Recommendation Taxonomy (SORT) was used to determine the overall strength of the recommendation. A random-effects meta-analysis was performed for all studies using the composite or total score. Data Synthesis: Eight studies with modified Downs and Black scores ranging from 70.6% to 88.4% were included. For question 1, the overall random-effects meta-analysis was weak (effect size = 0.27, 95% confidence interval = 0.14, 0.40; P \u3c .001). For question 2, the overall random-effects meta-analysis was moderate (effect size = 0.68, 95% confidence interval = 0.42, 0.95; P \u3c .001). Conclusions: Grade A evidence indicates that athletes reported better HRQOL than nonathletes and that uninjured athletes reported better HRQOL than injured athletes. However, the overall effect for question 1 was weak, suggesting that the differences between athletes and nonathletes may not be clinically meaningful. Clinicians should monitor HRQOL after injury to ensure that all dimensions of health are appropriately treated

Patient-Reported Outcome Measures in Individuals With Chronic Ankle Instability: A Systematic Review

Context: A comprehensive systematic literature review of the health-related quality-of-life (HRQOL) differences among individuals with chronic ankle instability (CAI), ankle-sprain copers, and healthy control participants has not been conducted. It could provide a better indication of the self-reported deficits that may be present in individuals with CAI. Objective: To systematically summarize the extent to which HRQOL deficits are present in individuals with CAI. Data Sources: We searched for articles in the electronic databases of EBSCO Host and PubMed Central using key words chronic, functional, mechanical, coper, instability, sprains, and patient-assessed. We also performed a hand search of reference lists, authors, and patient-reported outcomes (PROs) of the articles screened for inclusion. Study Selection: Studies were included if they (1) incorporated a PRO as a participant descriptor or as a study outcome to compare adults with CAI to ankle-sprain copers or healthy controls, (2) were written in English, and (3) were published in peer-reviewed journals. Data Extraction: Two authors independently assessed methodologic quality using the modified Downs and Black Index. Articles were filtered into 3 categories based on between-groups comparisons: CAI and copers, CAI and healthy control participants, copers and healthy participants. We calculated Hedges g effect sizes and 95% confidence intervals to examine PRO group differences. Data Synthesis: Of the 124 studies assessed for eligibility, 27 were included. A total of 24 articles compared PROs in individuals with CAI and healthy controls, 7 compared individuals with CAI and copers, and 4 compared copers and healthy controls. Quality scores on the modified Downs and Black Index ranged from 52.9% to 88.2%, with 8 high-, 16 moderate-, and 3 low-quality studies. Overall, we observed moderate to strong evidence that individuals with CAI displayed deficits on generic and region-specific PROs compared with copers and healthy controls. However, evidence that differences exist between copers and healthy controls was conflicting. In addition, for dimension-specific outcomes, evidence to suggest that fear of reinjury is heightened in individuals with CAI was limited. Conclusions: The evidence suggested that CAI is associated with functional and HRQOL deficits, particularly when examined with region-specific PROs. However, PROs do not appear to differ between copers and healthy controls

Health-Related Quality of Life in Individuals With Chronic Ankle Instability

Context: Individuals with chronic ankle instability (CAI) have reported decreased global and regional function. Despite the identification of functional deficits in those with CAI, more research is required to determine the extent to which CAI influences the multidimensional profile of health-related quality of life. Objective: To determine whether global, regional, and psychological health-related outcomes differ between individuals with and without CAI. Design: Case-control study. Setting: Laboratory. Patients or Other Participants: Twenty-five participants with CAI (age = 21.9 ± 2.5 years, height = 170.8 ± 8.6 cm, mass = 69.8.0 ± 11.7 kg) were sex- and limb-matched to 25 healthy participants (age = 22.0 ± 2.1 years, height = 167.4 ± 9.1 cm, mass = 64.8 ± 11.2 kg). Main Outcome Measure(s): Both groups completed the Disablement in the Physically Active Scale, the Foot and Ankle Ability Measure (FAAM), the FAAM-Sport, the Tampa Scale of Kinesiophobia-11, and the Fear-Avoidance Beliefs Questionnaire. Dependent variables were scores on these instruments, and the independent variable was group. Results: Compared with healthy individuals, those with CAI reported decreased function on the Disablement in the Physically Active Scale, FAAM, and FAAM-Sport (P \u3c .001) and increased fear of reinjury on the Tampa Scale of Kinesiophobia-11 and Fear-Avoidance Beliefs Questionnaire (P \u3c .001). In the CAI group, the FAAM and FAAM-Sport demonstrated a significant relationship (r = 0.774, P \u3c .01). Conclusions: Individuals with CAI reported decreased function and increased fear of reinjury compared with healthy control participants. Also, within the CAI group, there was a strong relationship between FAAM and FAAM-Sport scores but not between any other instruments. These findings suggest that health-related quality of life should be examined during the rehabilitation process of individuals with CAI

The Effectiveness of Whole-Body-Vibration Training in Improving Hamstring Flexibility in Physically Active Adults

Clinical Scenario: Hamstring tightness is common among physically active individuals. In addition to limiting range of motion and increasing the risk of muscle strain, hamstring tightness contributes to a variety of orthopedic conditions. Therefore, clinicians continue to identify effective methods to increase flexibility. Although hamstring tightness is typically treated with common stretching techniques such as static stretching and proprioceptive neuromuscular facilitation, it has been suggested that whole-body-vibration (WBV) training may improve hamstring flexibility. Clinical Question: Can WBV training, used in isolation or in combination with common stretching protocols or exercise, improve hamstring flexibility in physically active young adults? Summary of Key Findings: Of the included studies, 4 demonstrated statistically significant improvements in hamstring flexibility in the intervention group, and 1 study found minor improvements over time in the intervention group after treatment. Clinical Bottom Line: There is moderate evidence to support the use of WBV training to improve hamstring flexibility in physically active young adults. Strength of Recommendation: There is grade B evidence that WBV training improves hamstring flexibility in physically active adults. The Centre of Evidence Based Medicine recommends a grade of B for level 2 evidence with consistent findings

Patient-Reported Outcomes in Male and Female Collegiate Soccer Players During an Athletic Season

Context: Clinicians are urged to document patient-based outcomes during rehabilitation to measure health-related quality of life (HRQOL) from the patient\u27s perspective. It is unclear how scores on patient-reported outcome instruments (PROs) vary over the course of an athletic season because of normal athletic participation. Objective: Our primary purpose was to evaluate the effect of administration time point on HRQOL during an athletic season. Secondary purposes were to determine test-retest reliability and minimal detectable change scores of 3 PROs commonly used in clinical practice and if a relationship exists between generic and region-specific outcome instruments. Design: Cross-sectional study. Setting: Athletic facility. Patients or Other Participants: Twenty-three collegiate soccer athletes (11 men, 12 women). Main Outcome Measure(s): At 5 time points over a spring season, we administered the Disablement in the Physically Active Scale (DPA), Foot and Ankle Ability Measure-Sport, and Knee Injury and Osteoarthritis Outcome Score (KOOS). Results: Time effects were observed for the DPA (P = .011) and KOOS Quality of Life subscale (P = .027). However, the differences between individual time points did not surpass the minimal detectable change for the DPA, and no post hoc analyses were significant for the KOOS-Quality of Life subscale. Test-retest reliability was moderate for the KOOS-Pain subscale (intraclass correlation coefficient = 0.71) and good for the remaining KOOS subscales, DPA, and Foot and Ankle Ability Measure-Sport (intraclass correlation coefficients \u3e 0.79). The DPA and KOOS-Sport subscale demonstrated a significant moderate relationship (P = .018). Conclusions: Athletic participation during a nontraditional, spring soccer season did not affect HRQOL. All 3 PROs were reliable and could be used clinically to monitor changes in health status throughout an athletic season. Our results demonstrate that significant deviations in scores were related to factors other than participation, such as injury. Finally, both generic and region-specific instruments should be used in clinical practice

Descriptive Analysis of a Baseline Concussion Battery Among U.S. Service Academy Members: Results from the Concussion Assessment, Research, and Education (CARE) Consortium

Introduction The prevalence and possible long-term consequences of concussion remain an increasing concern to the U.S. military, particularly as it pertains to maintaining a medically ready force. Baseline testing is being used both in the civilian and military domains to assess concussion injury and recovery. Accurate interpretation of these baseline assessments requires one to consider other influencing factors not related to concussion. To date, there is limited understanding, especially within the military, of what factors influence normative test performance. Given the significant physical and mental demands placed on service academy members (SAM), and their relatively high risk for concussion, it is important to describe demographics and normative profile of SAMs. Furthermore, the absence of available baseline normative data on female and non-varsity SAMs makes interpretation of post-injury assessments challenging. Understanding how individuals perform at baseline, given their unique individual characteristics (e.g., concussion history, sex, competition level), will inform post-concussion assessment and management. Thus, the primary aim of this manuscript is to characterize the SAM population and determine normative values on a concussion baseline testing battery. Materials and Methods All data were collected as part of the Concussion Assessment, Research and Education (CARE) Consortium. The baseline test battery included a post-concussion symptom checklist (Sport Concussion Assessment Tool (SCAT), psychological health screening inventory (Brief Symptom Inventory (BSI-18) and neurocognitive evaluation (ImPACT), Balance Error Scoring System (BESS), and Standardized Assessment of Concussion (SAC). Linear regression models were used to examine differences across sexes, competition levels, and varsity contact levels while controlling for academy, freshman status, race, and previous concussion. Zero inflated negative binomial models estimated symptom scores due to the high frequency of zero scores. Results Significant, but small, sex effects were observed on the ImPACT visual memory task. While, females performed worse than males (p < 0.0001, pη2 = 0.01), these differences were small and not larger than the effects of the covariates. A similar pattern was observed for competition level on the SAC. There was a small, but significant difference across competition level. SAMs participating in varsity athletics did significantly worse on the SAC compared to SAMs participating in club or intramural athletics (all p’s < 0.001, η2 = 0.01). When examining symptom reporting, males were more than two times as likely to report zero symptoms on the SCAT or BSI-18. Intramural SAMs had the highest number of symptoms and severity compared to varsity SAMs (p < 0.0001, Cohen’s d < 0.2). Contact level was not associated with SCAT or BSI-18 symptoms among varsity SAMs. Notably, the significant differences across competition level on SCAT and BSI-18 were sub-clinical and had small effect sizes. Conclusion The current analyses provide the first baseline concussion battery normative data among SAMs. While statistically significant differences may be observed on baseline tests, the effect sizes for competition and contact levels are very small, indicating that differences are likely not clinically meaningful at baseline. Identifying baseline differences and significant covariates is important for future concussion-related analyses to inform concussion evaluations for all athlete levels

Association Between Sensation-Seeking Behaviors and Concussion-Related Knowledge, Attitudes, Perceived Norms, and Care-Seeking Behaviors among Collegiate Student-Athletes

There are limited data connecting personality and behavioral tendencies and traits related to concussion care-seeking/disclosure behaviors and minimal research exists surrounding the relationship between risky behaviors, sensation-seeking, and concussion-related outcomes. This study examined the association between sensation-seeking and a student-athlete’s concussion-related knowledge, attitudes, perceived social norms, and concussion care-seeking/disclosure behaviors (intention to disclose concussion symptoms, perceived control over symptom disclosure, self-removal from play due to concussion symptoms, continued play with concussion symptoms, and disclosure of all concussions at the time of injury). The current study utilized a retrospective cohort of collegiate student-athletes at a single National Collegiate Athletic Association Division I institution. Separate multivariable linear regression models estimating mean differences (MD) and 95% Confidence Intervals (CI) estimated the association between sensation-seeking and concussion knowledge, concussion attitudes, and perceived social norms. Separate multivariable binomial regression models estimating adjusted prevalence ratios (PR) and 95%CI estimated the association between sensation-seeking and intention to disclose concussion symptoms, perceived control over symptom disclosure, self-removal from play due to concussion symptoms, continued play with concussion symptoms, and disclosure of all concussions at the time of injury. All models were adjusted for sex, sport participation, and concussion history. Higher sensation-seeking was significantly associated with less favorable concussion attitudes (adjusted MD = -1.93; 95%CI = -3.04,-0.83), less favorable perceived social norms surrounding concussion (adjusted MD = -1.39; 95%CI = -2.06,-0.72), and continuing to play while experiencing concussion symptoms (adjusted PR = 1.50; 95%CI = 1.10, 2.06). Student-athletes with increased sensation-seeking could be at risk for failing to disclose a concussion, decreasing athlete safety and resulting in less optimal care post-injury. Results will inform future theory-based concussion education programs which consider behavioral tendencies and traits as well as sport culture to promote concussion care-seeking/disclosure and individualized interventions based on risky behavior engagement

Association of Blood Biomarkers With Acute Sport-Related Concussion in Collegiate Athletes: Findings From the NCAA and Department of Defense CARE Consortium

Importance: There is potential scientific and clinical value in validation of objective biomarkers for sport-related concussion (SRC). Objective: To investigate the association of acute-phase blood biomarker levels with SRC in collegiate athletes. Design, Setting, and Participants: This multicenter, prospective, case-control study was conducted by the National Collegiate Athletic Association (NCAA) and the US Department of Defense Concussion Assessment, Research, and Education (CARE) Consortium from February 20, 2015, to May 31, 2018, at 6 CARE Advanced Research Core sites. A total of 504 collegiate athletes with concussion, contact sport control athletes, and non-contact sport control athletes completed clinical testing and blood collection at preseason baseline, the acute postinjury period, 24 to 48 hours after injury, the point of reporting being asymptomatic, and 7 days after return to play. Data analysis was conducted from March 1 to November 30, 2019. Main Outcomes and Measures: Glial fibrillary acidic protein (GFAP), ubiquitin C-terminal hydrolase-L1 (UCH-L1), neurofilament light chain, and tau were quantified using the Quanterix Simoa multiplex assay. Clinical outcome measures included the Sport Concussion Assessment Tool-Third Edition (SCAT-3) symptom evaluation, Standardized Assessment of Concussion, Balance Error Scoring System, and Brief Symptom Inventory 18. Results: A total of 264 athletes with concussion (mean [SD] age, 19.08 [1.24] years; 211 [79.9%] male), 138 contact sport controls (mean [SD] age, 19.03 [1.27] years; 107 [77.5%] male), and 102 non-contact sport controls (mean [SD] age, 19.39 [1.25] years; 82 [80.4%] male) were included in the study. Athletes with concussion had significant elevation in GFAP (mean difference, 0.430 pg/mL; 95% CI, 0.339-0.521 pg/mL; P < .001), UCH-L1 (mean difference, 0.449 pg/mL; 95% CI, 0.167-0.732 pg/mL; P < .001), and tau levels (mean difference, 0.221 pg/mL; 95% CI, 0.046-0.396 pg/mL; P = .004) at the acute postinjury time point compared with preseason baseline. Longitudinally, a significant interaction (group × visit) was found for GFAP (F7,1507.36 = 16.18, P < .001), UCH-L1 (F7,1153.09 = 5.71, P < .001), and tau (F7,1480.55 = 6.81, P < .001); the interaction for neurofilament light chain was not significant (F7,1506.90 = 1.33, P = .23). The area under the curve for the combination of GFAP and UCH-L1 in differentiating athletes with concussion from contact sport controls at the acute postinjury period was 0.71 (95% CI, 0.64-0.78; P < .001); the acute postinjury area under the curve for all 4 biomarkers combined was 0.72 (95% CI, 0.65-0.79; P < .001). Beyond SCAT-3 symptom score, GFAP at the acute postinjury time point was associated with the classification of athletes with concussion from contact controls (β = 12.298; 95% CI, 2.776-54.481; P = .001) and non-contact sport controls (β = 5.438; 95% CI, 1.676-17.645; P = .005). Athletes with concussion with loss of consciousness or posttraumatic amnesia had significantly higher levels of GFAP than athletes with concussion with neither loss of consciousness nor posttraumatic amnesia at the acute postinjury time point (mean difference, 0.583 pg/mL; 95% CI, 0.369-0.797 pg/mL; P < .001). Conclusions and Relevance: The results suggest that blood biomarkers can be used as research tools to inform the underlying pathophysiological mechanism of concussion and provide additional support for future studies to optimize and validate biomarkers for potential clinical use in SRC

A cohort study to identify and evaluate concussion risk factors across multiple injury settings: findings from the CARE Consortium

BACKGROUND: Concussion, or mild traumatic brain injury, is a major public health concern affecting 42 million individuals globally each year. However, little is known regarding concussion risk factors across all concussion settings as most concussion research has focused on only sport-related or military-related concussive injuries. METHODS: The current study is part of the Concussion, Assessment, Research, and Education (CARE) Consortium, a multi-site investigation on the natural history of concussion. Cadets at three participating service academies completed annual baseline assessments, which included demographics, medical history, and concussion history, along with the Sport Concussion Assessment Tool (SCAT) symptom checklist and Brief Symptom Inventory (BSI-18). Clinical and research staff recorded the date and injury setting at time of concussion. Generalized mixed models estimated concussion risk with service academy as a random effect. Since concussion was a rare event, the odds ratios were assumed to approximate relative risk. RESULTS: Beginning in 2014, 10,604 (n = 2421, 22.83% female) cadets enrolled over 3 years. A total of 738 (6.96%) cadets experienced a concussion, 301 (2.84%) concussed cadets were female. Female sex and previous concussion were the most consistent estimators of concussion risk across all concussion settings. Compared to males, females had 2.02 (95% CI: 1.70-2.40) times the risk of a concussion regardless of injury setting, and greater relative risk when the concussion occurred during sport (Odds Ratio (OR): 1.38 95% CI: 1.07-1.78). Previous concussion was associated with 1.98 (95% CI: 1.65-2.37) times increased risk for any incident concussion, and the magnitude was relatively stable across all concussion settings (OR: 1.73 to 2.01). Freshman status was also associated with increased overall concussion risk, but was driven by increased risk for academy training-related concussions (OR: 8.17 95% CI: 5.87-11.37). Medical history of headaches in the past 3 months, diagnosed ADD/ADHD, and BSI-18 Somatization symptoms increased overall concussion risk. CONCLUSIONS: Various demographic and medical history factors are associated with increased concussion risk. While certain factors (e.g. sex and previous concussion) are consistently associated with increased concussion risk, regardless of concussion injury setting, other factors significantly influence concussion risk within specific injury settings. Further research is required to determine whether these risk factors may aid in concussion risk reduction or prevention