Point-of-Care Clinical Trials in Sports Medicine Research: Identifying Effective Treatment Interventions Through Comparative Effectiveness Research

CONTEXT

Recently, calls to conduct comparative effectiveness research (CER) in athletic training to better support patient care decisions have been circulated. Traditional research methods (eg, randomized controlled trials [RCTs], observational studies) may be ill suited for CER. Thus, innovative research methods are needed to support CER efforts.

OBJECTIVES

To discuss the limitations of traditional research designs in CER studies, describe a novel methodologic approach called the point-of-care clinical trial (POC-CT), and highlight components of the POC-CT (eg, incorporation of an electronic medical record [EMR], Bayesian adaptive feature) that allow investigators to conduct scientifically rigorous studies at the point of care.

DESCRIPTION

Practical concerns (eg, high costs and limited generalizability of RCTs, the inability to control for bias in observational studies) may stall CER efforts in athletic training. In short, the aim of the POC-CT is to embed a randomized pragmatic trial into routine care; thus, patients are randomized to minimize potential bias, but the study is conducted at the point of care to limit cost and improve the generalizability of the findings. Furthermore, the POC-CT uses an EMR to replace much of the infrastructure associated with a traditional RCT (eg, research team, patient and clinician reminders) and a Bayesian adaptive feature to help limit the number of patients needed for the study. Together, the EMR and Bayesian adaptive feature can improve the overall feasibility of the study and preserve the typical clinical experiences of the patient and clinician.

CLINICAL ADVANTAGES

The POC-CT includes the basic tenets of practice-based research because studies are conducted at the point of care, in real-life settings, and during routine clinical practice. If implemented effectively, the POC-CT can be seamlessly integrated into daily clinical practice, allowing investigators to establish patient-reported evidence that may be quickly applied to patient care decisions. This design appears to be a promising approach for CER investigations and may help establish a "learning health care system" in the sports medicine community.

The First Decade of Web-Based Sports Injury Surveillance: Descriptive Epidemiology of Injuries in US High School Girls' Softball (2005-2006 Through 2013-2014) and National Collegiate Athletic Association Women's Softball (2004-2005 Through 2013-2014)

CONTEXT

The advent of Web-based sports injury surveillance via programs such as the High School Reporting Information Online system and the National Collegiate Athletic Association Injury Surveillance Program has aided the acquisition of girls' and women's softball injury data.

OBJECTIVE

To describe the epidemiology of injuries sustained in high school girls' softball in the 2005-2006 through 2013-2014 academic years and collegiate women's softball in the 2004-2005 through 2013-2014 academic years using Web-based sports injury surveillance.

DESIGN

Descriptive epidemiology study.

SETTING

Online injury surveillance from softball teams in high school girls (annual average = 100) and collegiate women (annual average = 41).

PATIENTS OR OTHER PARTICIPANTS

Girls' or women's softball players who participated in practices and competitions during the 2005-2006 through 2013-2014 academic years in high school and the 2004-2005 through 2013-2014 academic years in college.

MAIN OUTCOME MEASURE(S)

Athletic trainers collected time-loss injury and exposure data. Injury rates per 1000 athlete-exposures (AEs) were calculated. Injury rate ratios (IRRs) with 95% confidence intervals (CIs) compared injury rates by competition level, school size or division, event type, and time in season.

RESULTS

The High School Reporting Information Online system documented 1357 time-loss injuries during 1 173 722 AEs; the National Collegiate Athletic Association Injury Surveillance Program documented 1848 time-loss injuries during 579 553 AEs. The injury rate was higher in college than in high school (3.19 versus 1.16/1000 AEs; IRR = 2.76; 95% CI = 2.57, 2.96). The competition injury rate was higher than the practice injury rate in high school (IRR = 2.02; 95% CI = 1.82, 2.25) and in college (IRR = 1.39; 95% CI = 1.27, 1.52). Softball players at both levels sustained a variety of injuries, with the most common being ankle sprains and concussions. Many injuries also occurred while fielding or running bases.

CONCLUSIONS

Injury rates were greater in collegiate versus high school softball and in competitions versus practices. These findings highlight the need for injury-prevention interventions, including strength-training and prevention programs to reduce ankle sprains and provide protection for batters from pitches and fielders from batted balls.

The First Decade of Web-Based Sports Injury Surveillance: Descriptive Epidemiology of Injuries in US High School Boys' Baseball (2005-2006 Through 2013-2014) and National Collegiate Athletic Association Men's Baseball (2004-2005 Through 2013-2014)

CONTEXT

The advent of Web-based sports injury surveillance via programs such as the High School Reporting Information Online system and the National Collegiate Athletic Association Injury Surveillance Program has aided the acquisition of boys' and men's baseball injury data.

OBJECTIVE

To describe the epidemiology of injuries sustained in high school boys' baseball in the 2005-2006 through 2013-2014 academic years and collegiate men's baseball in the 2004-2005 through 2013-2014 academic years using Web-based sports injury surveillance.

DESIGN

Descriptive epidemiology study.

SETTING

Online injury surveillance from baseball teams in high school boys (annual average = 100) and collegiate men (annual average = 34).

PATIENTS OR OTHER PARTICIPANTS

Boys' or men's baseball players who participated in practices and competitions during the 2005-2006 through 2013-2014 academic years in high school or the 2004-2005 through 2013-2014 academic years in college, respectively.

MAIN OUTCOME MEASURE(S)

Athletic trainers collected time-loss injury and exposure data. Injury rates per 1000 athlete-exposures (AEs) were calculated. Injury rate ratios (IRRs) with 95% confidence intervals (CIs) compared injury rates by school size or division, time in season, event type, and competition level.

RESULTS

The High School Reporting Information Online system documented 1537 time-loss injuries during 1 573 257 AEs; the National Collegiate Athletic Association Injury Surveillance Program documented 2574 time-loss injuries during 804 737 AEs. The injury rate was higher in college than in high school (3.20 versus 0.98/1000 AEs; IRR = 3.27; 95% CI = 3.07, 3.49). The competition injury rate was higher than the practice injury rate in high school (IRR = 2.27; 95% CI = 2.05, 2.51) and college (IRR = 2.32; 95% CI = 2.15, 2.51). Baseball players at the high school and collegiate levels sustained a variety of injuries across the body, with the most common injuries reported to the upper extremity. Many injuries also occurred while fielding or pitching.

CONCLUSIONS

Injury rates were greater in collegiate versus high school baseball and in competition versus practice. These findings highlight the need for injury-prevention interventions focused on reducing the incidence of upper extremity injuries and protecting batters from pitches and fielders from batted balls.

Quality Improvement in Athletic Health Care

CONTEXT

  Quality improvement (QI) is a health care concept that ensures patients receive high-quality (safe, timely, effective, efficient, equitable, patient-centered) and affordable care. Despite its importance, the application of QI in athletic health care has been limited.

OBJECTIVES

  To describe the need for and define QI in health care, to describe how to measure quality in health care, and to present a QI case in athletic training.

DESCRIPTION

  As the athletic training profession continues to grow, a widespread engagement in QI efforts is necessary to establish the value of athletic training services for the patients that we serve. A review of the importance of QI in health care, historical perspectives of QI, tools to drive QI efforts, and examples of common QI initiatives is presented to assist clinicians in better understanding the value of QI for advancing athletic health care and the profession. Clinical and Research Advantages:  By engaging clinicians in strategies to measure outcomes and improve their patient care services, QI practice can help athletic trainers provide high-quality and affordable care to patients.

The Functional Arm Scale for Throwers (FAST)-Part I: The Design and Development of an Upper Extremity Region-Specific and Population-Specific Patient-Reported Outcome Scale for Throwing Athletes

BACKGROUND

Upper extremity (UE) region-specific, patient-reported outcome (PRO) scales assess injuries to the UE but do not account for the demands of overhead throwing athletes or measure patient-oriented domains of health-related quality of life (HRQOL).

PURPOSE

To develop the Functional Arm Scale for Throwers (FAST), a UE region-specific and population-specific PRO scale that assesses multiple domains of disablement in throwing athletes with UE injuries. In stage I, a beta version of the scale was developed for subsequent factor identification, final item reduction, and construct validity analysis during stage II.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Three-stage scale development was utilized: Stage I (item generation and initial item reduction) and stage II (factor analysis, final item reduction, and construct validity) are reported herein, and stage III (establishment of measurement properties [reliability and validity]) will be reported in a companion paper. In stage I, a beta version was developed, incorporating National Center for Medical Rehabilitation Research disablement domains and ensuring a blend of sport-related and non-sport-related items. An expert panel and focus group assessed importance and interpretability of each item. During stage II, the FAST was reduced, preserving variance characteristics and factor structure of the beta version and construct validity of the final FAST scale.

RESULTS

During stage I, a 54-item beta version and a separate 9-item pitcher module were developed. During stage II, a 22-item FAST and 9-item pitcher module were finalized. The factor solution for FAST scale items included pain (n = 6), throwing (n = 10), activities of daily living (n = 5), psychological impact (n = 4), and advancement (n = 3). The 6-item pain subscale crossed factors. The remaining subscales and pitcher module are distinctive, correlated, and internally consistent and may be interpreted individually or combined.

CONCLUSION

This article describes the development of the FAST, which assesses clinical outcomes and HRQOL of throwing athletes after UE injury. The FAST encompasses multiple domains of disability and demonstrates excellent construct validity.

CLINICAL RELEVANCE

The FAST provides a single UE region-specific and population-specific PRO scale for high-demand throwers to facilitate measurement of impact of UE injuries on HRQOL and clinical outcomes while quantifying recovery for comparative effectiveness studies.

The Functional Arm Scale for Throwers (FAST)-Part II: Reliability and Validity of an Upper Extremity Region-Specific and Population-Specific Patient-Reported Outcome Scale for Throwing Athletes

Background:

The Functional Arm Scale for Throwers (FAST) is an upper extremity (UE) region-specific and population-specific patient-reported outcome (PRO) scale developed to measure health-related quality of life in throwers with UE injuries. Stages I and II, described in a companion paper, of FAST development produced a 22-item scale and a 9-item pitcher module. Stage III of scale development, establishing reliability and validity of the FAST, is reported herein.

Purpose:

To describe stage III of scale development: reliability and validity of the FAST.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

Data from throwing athletes collected over 5 studies were pooled to assess reliability and validity of the FAST. Reliability was estimated using FAST scores from 162 throwing athletes who were injured (n = 23) and uninjured (n = 139). Concurrent validity was estimated using FAST scores and Disabilities of the Arm, Shoulder, and Hand (DASH) and Kerlan-Jobe Orthopaedic Clinic (KJOC) scores from 106 healthy, uninjured throwing athletes. Known-groups validity was estimated using FAST scores from 557 throwing athletes who were injured (n = 142) and uninjured (n = 415). Reliability and validity were assessed using intraclass correlation coefficients (ICCs), and measurement error was assessed using standard error of measurement (SEM) and minimum detectable change (MDC). Receiver operating characteristic curves and sensitivity/specificity values were estimated for known-groups validity. Data from a separate group (n = 18) of postsurgical and nonoperative/conservative rehabilitation patients were analyzed to report responsiveness of the FAST.

Results:

The FAST total, subscales, and pitcher module scores demonstrated excellent test-retest reliability (ICC, 0.91-0.98). The SEM₉₅ and MDC₉₅ for the FAST total score were 3.8 and 10.5 points, respectively. The SEM₉₅ and MDC₉₅ for the pitcher module score were 5.7 and 15.7 points, respectively. The FAST scores showed acceptable correlation with DASH (ICC, 0.49-0.82) and KJOC (ICC, 0.62-0.81) scores. The FAST total score classified 85.1% of players into the correct injury group. For predicting UE injury status, a FAST total cutoff score of 10.0 out of 100.0 was 91% sensitive and 75% specific, and a pitcher module score of 10.0 out of 100.0 was 87% sensitive and 78% specific. The FAST total score demonstrated responsiveness on several indices between intake and discharge time points.

Conclusion:

The FAST is a reliable, valid, and responsive UE region-specific and population-specific PRO scale for measuring patient-reported health care outcomes in throwing athletes with injury.

Hip and glenohumeral rotational range of motion in healthy professional baseball pitchers and position players

BACKGROUND

Research suggests that limitations in the hip motion of baseball players may lead to altered motion at the glenohumeral joint to maintain throwing velocity, thereby predisposing the upper extremity to injury.

PURPOSE

To measure and evaluate the correlation between hip and shoulder rotational range of motion (ROM) in healthy professional baseball players.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Ninety-nine professional baseball players (50 pitchers and 49 position players; mean age ± standard deviation [SD], 22 ± 2.8 years; mean height ± SD, 187 ± 5.4 cm; mean weight ± SD, 81.6 ± 7.7 kg) with no history of hip or shoulder injury were tested. Dominant and nondominant hip and glenohumeral joints were measured for the following passive ROM variables: (1) hip internal rotation (IR), (2) hip external rotation (ER), (3) total hip rotational ROM (IR + ER), (4) isolated glenohumeral IR, (5) isolated glenohumeral ER, and (6) total glenohumeral rotational ROM (IR + ER).

RESULTS

Statistically, hip ER and total hip rotational ROM were greater in position players than in pitchers and less in the lead leg compared with the stance leg hip with groups combined; however, differences are not clinically meaningful. Pitchers had more glenohumeral rotational ROM than did position players. For all players, glenohumeral motion had less IR and greater ER in the throwing arm than the nonthrowing arm, but total glenohumeral rotational ROM was equivalent between sides. The correlations between hip and glenohumeral ROM were little, if any, and ranged from r = -0.19 to 0.11 (P = .006-.94) for all players and r = -0.29 to 0.23 (P = .04-.97) for pitchers only.

CONCLUSION

These data suggest no clinically meaningful differences in hip ROM between pitchers and position players and between lead leg and stance legs of all players. There is little or no relationship between hip and glenohumeral ROM in healthy professional baseball players.

CLINICAL RELEVANCE

The study findings add to the growing body of evidence that suggests an absence of chronic hip ROM adaptations. It is therefore suggested that in the hip, unlike the glenohumeral joint, symmetry in ROM between player positions and dominant and nondominant sides should be expected in healthy professional baseball pitchers and position players.

Practice-based research networks, part II: a descriptive analysis of the athletic training practice-based research network in the secondary school setting

CONTEXT

Analysis of health care service models requires the collection and evaluation of basic practice characterization data. Practice-based research networks (PBRNs) provide a framework for gathering data useful in characterizing clinical practice.

OBJECTIVE

To describe preliminary secondary school setting practice data from the Athletic Training Practice-Based Research Network (AT-PBRN).

DESIGN

Descriptive study.

SETTING

Secondary school athletic training facilities within the AT-PBRN.

PATIENTS OR OTHER PARTICIPANTS

Clinicians (n = 22) and their patients (n = 2523) from the AT-PBRN.

MAIN OUTCOME MEASURE(S)

A Web-based survey was used to obtain data on clinical practice site and clinician characteristics. Patient and practice characteristics were obtained via deidentified electronic medical record data collected between September 1, 2009, and April 1, 2011. Descriptive data regarding the clinician and CPS practice characteristics are reported as percentages and frequencies. Descriptive analysis of patient encounters and practice characteristic data was performed, with the percentages and frequencies of the type of injuries recorded at initial evaluation, type of treatment received at initial evaluation, daily treatment, and daily sign-in procedures.

RESULTS

The AT-PBRN had secondary school sites in 7 states, and most athletic trainers at those sites (78.2%) had less than 5 years of experience. The secondary school sites within the AT-PBRN documented 2523 patients treated across 3140 encounters. Patients most frequently sought care for a current injury (61.3%), followed by preventive services (24.0%), and new injuries (14.7%). The most common diagnoses were ankle sprain/strain (17.9%), hip sprain/strain (12.5%), concussion (12.0%), and knee pain (2.5%). The most frequent procedures were athletic trainer evaluation (53.9%), hot- or cold-pack application (26.0%), strapping (10.3%), and therapeutic exercise (5.7%). The median number of treatments per injury was 3 (interquartile range = 2, 4; range = 2-19).

CONCLUSIONS

These preliminary data describe services provided by clinicians within the AT-PBRN and demonstrate the usefulness of the PBRN model for obtaining such data.

Practice-based research networks, part I: clinical laboratories to generate and translate research findings into effective patient care

CONTEXT

To improve patient care, athletic training clinicians and researchers should work together to translate research findings into clinical practice. Problems with patient care observed in clinical practice should be translated into research frameworks, where they can be studied. Practice-based research networks (PBRNs) provide a compelling model for linking clinicians and researchers so they can conduct translational research to improve patient care.

OBJECTIVE

To describe (1) the translational research model, (2) practice-based research as a mechanism for translating research findings into clinical practice, (3) the PBRN model and infrastructure, (4) the research potential using the PBRN model, and (5) protection of human participants in PBRN research.

DESCRIPTION

Translational research is the process of transforming research findings into health behavior that ultimately serves the public and attempts to bridge the gap between research and clinical practice. Practice-based research represents the final step in the translational research continuum and describes research conducted by providers in clinical practices. The PBRNs are characterized by an organizational framework that transcends a single site or study and serves as the clinical research "laboratory" for conducting comparative-effectiveness studies using patient-oriented measures. The PBRN approach to research has many benefits, including enhanced generalizability of results, pooling of resources, rapid patient recruitment, and collaborative opportunities. However, multisite research also brings challenges related to the protection of human participants and institutional review board oversight. CLINICAL AND RESEARCH ADVANTAGES: Athletic training studies frequently include relatively few participants and, consequently, are able to detect only large effects. The incidence of injury at a single site is sufficiently low that gathering enough data to adequately power a treatment study may take many years. Collaborative efforts across diverse clinical practice environments can yield larger patient samples to overcome the limitations inherent in single-site research efforts.

Recent injury and health-related quality of life in adolescent athletes

CONTEXT

Health-related quality of life (HRQOL) is a global concept that takes into account the physical, psychological, and social domains of health. Determining the extent to which injury affects HRQOL is an important aspect of rehabilitation practice, enabling comparisons of clinical outcomes across different conditions in diverse patient groups.

OBJECTIVE

To examine the extent to which a self-reported recent injury affected HRQOL in adolescent athletes using 2 generic patient self-report scales.

DESIGN

Cross-sectional study.

SETTING

High school classrooms and athletic training facilities.

PATIENTS OR OTHER PARTICIPANTS

A convenience sample of uninjured (n = 160) and injured (n = 45) adolescent athletes.

INTERVENTION(S)

THE INDEPENDENT VARIABLE WAS INJURY STATUS: uninjured versus injured. All participants completed a self-administered brief health status questionnaire and the Short Form-36 Health Survey Questionnaire (SF-36) and Pediatric Outcomes Data Collection Instrument (PODCI) in a counterbalanced manner.

MAIN OUTCOME MEASURE(S)

Dependent variables included 8 subscale and 2 composite scores of the SF-36 and 5 subscale scores and 1 global score of the PODCI. Group differences were assessed with the Mann-Whitney U test (P < or = .05) and reported as median and interquartile range.

RESULTS

On the SF-36, the injured group demonstrated lower scores (P < .008) for physical functioning, limitations due to physical health problems, bodily pain, social functioning, and the physical composite. On the PODCI, the injured group reported lower scores (P < .01) on the pain and comfort subscale and the global score.

CONCLUSIONS

Adolescent athletes with self-reported injuries demonstrated lower HRQOL than their uninjured peers. As expected, recent injury affected physical functioning and pain. Social functioning (on the SF-36) and global HRQOL (on the PODCI) also decreased, suggesting that injuries affected areas beyond the expected physical component of health. Clinicians need to recognize the full spectrum of negative influences that injuries may have on HRQOL in adolescent athletes.

Using disablement models and clinical outcomes assessment to enable evidence-based athletic training practice, part I: disablement models

OBJECTIVE

To present and discuss disablement models and the benefits of using these models as a framework to assess clinical outcomes in athletic training.

BACKGROUND

Conceptual schemes that form the basic architecture for clinical practice, scholarly activities, and health care policy, disablement models have been in use by health care professions since the 1960s. Disablement models are also the foundation for clinical outcomes assessment. Clinical outcomes assessment serves as the measurement tool for patient-oriented evidence and is a necessary component for evidence-based practice.

DESCRIPTION

Disablement models provide benefits to health professions through organization of clinical practice and research activities; creation of a common language among health care professionals; facilitation of the delivery of patient-centered, whole-person health care; and justification of interventions based on a comprehensive assessment of the effect of illness or injury on a person's overall health-related quality of life. Currently, the predominant conceptual frameworks of disability in health care are those of the National Center for Medical Rehabilitation Research and the World Health Organization. Disablement models need to be understood, used, and studied by certified athletic trainers to promote patient-centered care and clinical outcomes assessment for the development of evidence-based practice in athletic training. CLINICAL AND RESEARCH ADVANTAGES: For clinicians and researchers to determine effective athletic training treatments, prevention programs, and practices, they must understand what is important to patients by collecting patient-oriented evidence. Patient-oriented evidence is the most essential form of outcomes evidence and necessitates an appreciation of all dimensions of health, as outlined by disablement models. The use of disablement models will allow the athletic training profession to communicate, measure, and prioritize the health care needs of patients, which will facilitate organized efforts aimed at assessing the quality of athletic training services and practices and ultimately promote successful evidence-based athletic training practice.

Using disablement models and clinical outcomes assessment to enable evidence-based athletic training practice, part II: clinical outcomes assessment

OBJECTIVE

To provide an overview of clinical outcomes assessment, discuss the classification of outcomes measures, present considerations for choosing outcomes scales, identify the importance of assessing clinical outcomes, and describe the critical link between the utilization of disablement models and clinical outcomes assessment.

BACKGROUND

Clinical outcomes are the end result of health care services. Clinical outcomes assessment is based on the conceptual framework of disablement models and serves as the measurement method for the collection of patient-oriented evidence, a concept central to evidence-based practice.

DESCRIPTION

Clinical outcomes management refers to the use of outcomes measures in the course of routine clinical care and provides athletic trainers with a mechanism to assess treatment progress and to measure the end results of the services they provide. Outcomes measures can be classified as either clinician based or patient based. Clinician-based measures, such as range of motion and strength, are taken directly by clinicians. Patient-based measures solicit a patient's perception as to health status in the form of questionnaires and survey scales. Clinician-based measures may assist with patient evaluation, but patient-based measures should always be included in clinical assessment to identify what is important to the patient. CLINICAL AND RESEARCH ADVANTAGES: Evidence-based athletic training practice depends on clinical outcomes research to provide the foundation of patient-oriented evidence. The widespread use of clinical outcomes assessment, based on the disablement model framework, will be necessary for athletic trainers to demonstrate the effectiveness of therapies and interventions, the provision of patient-centered care, and the development of evidence-based practice guidelines.

Review for librarians of evidence-based practice in nursing and the allied health professions in the United States

OBJECTIVE

This paper provides an overview of the state of evidence-based practice (EBP) in nursing and selected allied health professions and a synopsis of current trends in incorporating EBP into clinical education and practice in these fields. This overview is intended to better equip librarians with a general understanding of the fields and relevant information resources. INCLUDED PROFESSIONS: Professions are athletic training, audiology, health education and promotion, nursing, occupational therapy, physical therapy, physician assisting, respiratory care, and speech-language pathology.

APPROACH

Each section provides a description of a profession, highlighting changes that increase the importance of clinicians' access to and use of the profession's knowledgebase, and a review of each profession's efforts to support EBP. The paper concludes with a discussion of the librarian's role in providing EBP support to the profession.

CONCLUSIONS

EBP is in varying stages of growth among these fields. The evolution of EBP is evidenced by developments in preservice training, growth of the literature and resources, and increased research funding. Obstacles to EBP include competing job tasks, the need for additional training, and prevalent attitudes and behaviors toward research among practitioners. Librarians' skills in searching, organizing, and evaluating information can contribute to furthering the development of EBP in a given profession.

Descriptive epidemiology of collegiate men's baseball injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004

OBJECTIVE

To review 16 years of National Collegiate Athletic Association (NCAA) injury surveillance data for men's baseball and identify potential areas for injury prevention initiatives.

BACKGROUND

Prevention and management of collegiate baseball injuries may be facilitated through injury research aimed at defining the nature of injuries inherent in the sport. Through the NCAA Injury Surveillance System, 16 years of collegiate baseball data were collected for the academic years 1988-1989 through 2003-2004.

MAIN RESULTS

College baseball has a relatively low rate of injury compared with other NCAA sports, but 25% of injuries are severe and result in 10+ days of time loss from participation. The rate of injury was 3 times higher in a game situation than in practice (5.78 versus 1.85 injuries per 1000 athlete-exposures [A-Es], rate ratio = 3.1, 95% confidence interval = 3.0, 3.3, P < .01). Practice injury rates were almost twice as high in the preseason as in the regular season (2.97 versus 1.58 per 1000 A-Es, rate ratio = 1.9, 95% confidence interval = 1.8, 2.0, P < .01). A total of 10% of all game injuries occurred from impact with a batted ball, an injury rate of 0.56 injuries per 1000 game A-Es. Sliding was involved in 13% of game injuries.

RECOMMENDATIONS

Proper preseason conditioning is important to reduce injuries. Athletic trainers covering practices and games should be prepared to deal with serious, life-threatening injuries from batted balls and other injury mechanisms. Further study of batted-ball injuries is warranted, and the use of breakaway bases to prevent sliding injuries should be supported in college baseball.

Laxity testing of the shoulder: a review

Laxity testing is an important part of the examination of any joint. In the shoulder, it presents unique challenges because of the complexity of the interactions of the glenohumeral and scapulothoracic joints. Many practitioners believe that laxity testing of the shoulder is difficult, and they are unclear about its role in evaluation of patients. The objectives of the various laxity and instability tests differ, but the clinical signs of such tests can provide helpful information about joint stability. This article summarizes the principles of shoulder laxity testing, reviews techniques for measuring shoulder laxity, and evaluates the clinical usefulness of the shoulder laxity tests. Shoulder laxity evaluation can be a valuable element of the shoulder examination in patients with shoulder pain and instability.

Glenohumeral joint laxity and stiffness in the functional throwing position of high school baseball pitchers

CONTEXT

Repetitive overhead throwing has been theorized to result in chronic adaptations to the capsuloligamentous restraints of the glenohumeral joint.

OBJECTIVE

To compare glenohumeral joint laxity and stiffness between the throwing and nonthrowing shoulders of high school baseball pitchers.

DESIGN

Repeated measures.

SETTING

High school athletic training facilities.

PATIENTS OR OTHER PARTICIPANTS

Twenty-two asymptomatic high school baseball pitchers (age = 16.50 +/- 0.74 years, height = 178.51 +/- 7.66 cm, mass = 75.43 +/- 13.24 kg) from a sample of convenience.

MAIN OUTCOMES MEASURE(S)

We used computerized stress arthrometry to measure glenohumeral joint laxity and stiffness. Anterior glenohumeral joint laxity and stiffness measures were obtained with the shoulder in 90 degrees of abduction and both neutral rotation and 90 degrees of external rotation. Posterior laxity and stiffness measures were obtained with the shoulder in 90 degrees of abduction and neutral rotation.

RESULTS

No clinically significant differences were found for glenohumeral laxity or stiffness between sides. However, a statistically significant main effect for position was present for both laxity and stiffness. Anterior glenohumeral joint laxity in the 90 degrees external rotation position was significantly decreased and stiffness was increased in this position compared with the anterior at neutral and posterior at neutral positions.

CONCLUSIONS

Glenohumeral joint laxity decreases and stiffness increases in the functional throwing position of 90 degrees of abduction and 90 degrees of external rotation. No clinically significant side-to-side differences or directional differences were found in high school baseball pitchers.

Effectiveness of rehabilitation for patients with subacromial impingement syndrome

Reference: Michener LA, Walsworth MK, Burnet EN. Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. J Hand Ther. 2004;17: 152–164.

Clinical Question: Which physical rehabilitation techniques are effective in reducing pain and functional loss for patients with subacromial impingement syndrome (SAIS)?

Data Sources: Investigations were identified by MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials Register searches from 1966 through October 2003 and by hand searching the references of all retrieved articles and relevant conference proceedings. The search terms were shoulder, shoulder impingement syndrome, bursitis, and rotator cuff combined with rehabilitation, physical therapy, electrotherapy, ultrasound, exercise, and acupuncture and limited to clinical trial, random assignment, or placebo.

Study Selection: Inclusion criteria involved randomized controlled trials or clinical trials comparing nonsurgical, nonpharmacologic physical interventions for patients with SAIS with another intervention, no treatment, or a placebo treatment. Included studies required clinically relevant and well-described outcome measures of pain, disability, or functional loss. The study was limited to adult patients who met specific inclusion criteria for the signs and symptoms of SAIS and exclusion criteria for systemic impairment, cervical involvement, degenerative joint changes, clinical findings of other shoulder injury, previous history of surgery or physical therapy treatment, and workers' compensation claim/litigation.

Data Extraction: A 23-item checklist, with each item assigned 0, 1, or 2 quality points for a total of 46 possible points, was used independently by 2 examiners to assess each study. In their original report, Michener et al stated that the 23-item checklist was worth a possible 69 points. However, in a conversation with L. A. Michener, she stated that this was an inadvertent publication error and confirmed that the possible point value for this checklist was indeed 46. This checklist encompasses 7 major areas, including the rationale for the research question, study design, subjects, intervention, outcome, analysis, and recommendations. If a discrepancy of more than 1 quality point was present for any item, the 2 investigators discussed it to reach a consensus. The total quality points were summed for each independent evaluator, and the average of the 2 final scores was used to determine the total quality score for an individual study.

Main Results: The specific search criteria identified a total of 635 papers for review, of which only 12 met the inclusion and exclusion criteria for study. The average total quality score of these 12 studies was 37.6 (range, 33.5–41) of 46 possible points. Analysis of the inclusion criteria for SAIS revealed that shoulder pain was present in all 12 trials, painful or weak resisted abduction was present in 7 trials, positive Neer test was present in 6 trials, painful arc was present in 5 trials, positive Hawkins-Kennedy test was present in 4 trials, painful or weak resisted shoulder internal and external rotation in 4 trials, and positive impingement injection test was present in 2 trials. Physical interventions, performed in isolation or in combination, for patients with SAIS were divided into 5 types: exercise, joint mobilization, ultrasound, acupuncture, and laser. Authors employed a variety of outcomes measures, with all studies using a numeric rating or visual analog scale for pain, a direct measure of functional loss or disability (in 10 of 12 studies), or an indirect measure of a global rating of change or a measure of strength in a functional position (in 2 of 12 studies). Therapeutic exercise was the most widely studied form of physical intervention and demonstrated short-term and long-term effectiveness for decreasing pain and reducing functional loss. Upper quarter joint mobilizations in combination with therapeutic exercise were more effective than exercise alone. Laser therapy is an effective single intervention when compared with placebo treatments, but adding laser treatment to therapeutic exercise did not improve treatment efficacy. The limited data available do not support the use of ultrasound as an effective treatment for reducing pain or functional loss. Two studies evaluating the effectiveness of acupuncture produced equivocal results.

Conclusions: These data indicate that exercise, joint mobilization, and laser therapy are effective physical interventions for decreasing pain and functional loss or disability for patients with SAIS. The current evidence does not support the use of ultrasound, and studies evaluating the effectiveness of acupuncture were equivocal. The number of trials evaluating the effectiveness of physical rehabilitation interventions for patients with SAIS is limited, and those available are of moderate quality. Clinicians should interpret the conclusions with these limitations in mind.

Clinical Measures of Shoulder Mobility in the Professional Baseball Player

Context: Professional baseball players must achieve a delicate balance between shoulder mobility and stability to attain optimal sports performance. The sport-specific demands of repetitive overhead throwing may result in an altered mobility-stability relationship.Objective: To evaluate clinical measures of shoulder mobility in professional baseball players in order to examine differences between the throwing and the nonthrowing shoulders and to describe chronic adaptations to throwing.Design: Descriptive.Setting: The athletic training room at Maryvale Baseball Park, Phoenix, AZ.Patients or Other Participants: Twenty-seven professional baseball players (20 pitchers, 7 position players; age = 20 +/- 1.6 years, height = 190.5 +/- 4.8 cm, mass = 91.6 +/- 9.6 kg) with no previous history of shoulder or elbow injury.Main Outcome Measure(s): We recorded scapular upward rotation at 4 levels of humeral elevation in the scapular plane (rest, 60 degrees , 90 degrees , 120 degrees ); posterior shoulder tightness; and passive, isolated glenohumeral joint internal and external range of motion.Results: Scapular upward rotation was significantly greater in the throwing shoulder (14.2 +/- 6.5 degrees ) than in the nonthrowing shoulder (10.6 +/- 6.1 degrees ) at 90 degrees of humeral elevation (P = .04). We observed no statistically significant difference in posterior shoulder tightness between the throwing (30.2 +/- 4.6 cm) and the nonthrowing (28.0 +/- 4.8 cm) shoulder (P = .09). In addition, the throwing shoulder exhibited a statistically significant decrease in isolated glenohumeral internal rotation (56.6 +/- 12.5 degrees ) compared with the nonthrowing shoulder (68.6 +/- 12.6 degrees ) (P = .001), with a concomitant increase in isolated glenohumeral external rotation (throwing = 108.9 +/- 9.0 degrees , nonthrowing = 101.9 +/- 5.9 degrees , P = .0014). An analysis of the total arc of motion (internal rotation + external rotation) revealed no statistically significant difference between sides (P = .15).Conclusions: The throwing shoulder exhibited significant differences in scapular and glenohumeral mobility compared with the nonthrowing shoulder. Further research is necessary to determine the relation of these adaptive changes, if any, to shoulder injury and disability.

Scapular-Positioning Patterns During Humeral Elevation in Unimpaired Shoulders

OBJECTIVE: To assess scapular-positioning patterns using a static measurement technique. DESIGN AND SETTING: We used a 4-within-factor design to compare scapular upward rotation among subjects. The within factors included side (dominant, nondominant), plane of motion (scapular, sagittal), direction of motion (ascending, descending), and level of humeral rotation (rest, 30 degrees, 60 degrees, 90 degrees, 120 degrees ). SUBJECTS: Twenty-seven subjects with unimpaired shoulders. MEASUREMENTS: We measured scapular position and glenohumeral range of motion using a digital inclinometer and goniometer, respectively. All measurements were performed bilaterally. RESULTS: Between-session repeatability was poor to excellent depending on humeral-elevation angle. The scapular plane demonstrated significantly more scapular upward rotation than did the sagittal plane at 120 degrees of humeral elevation. CONCLUSIONS: The scapula demonstrated a consistent pattern of downward rotation initially from rest to 30 degrees of humeral elevation, followed by an upward rotation after 30 degrees of humeral elevation to the highest level (120 degrees ). Scapular upward rotation is greater in the scapular plane than in the sagittal plane. Therefore, overhead rehabilitation exercises should be performed in the scapular plane, especially in subjects with rotator cuff tendinopathy.

Glenohumeral Stiffness Response Between Men and Women for Anterior, Posterior, and Inferior Translation

OBJECTIVE: To quantify and compare the glenohumeral stiffness response in anterior-directed, posterior-directed, and inferior-directed translations in healthy men and women. DESIGN AND SETTING: We used a 2 division on times 3 factorial design and employed a device capable of measuring glenohumeral joint displacement as a function of force to gather kinematic data during a single test session. SUBJECTS: Twenty subjects with healthy nondominant shoulders participated in the study. MEASUREMENTS: Force-displacement measures were taken in the anterior, posterior, and inferior translational directions of the glenohumeral joint. These measurements simulated common laxity tests used at the shoulder. RESULTS: Analysis of variance revealed a nonsignificant sex division on times direction interaction effect (P >.05). The main effect for sex and direction was also not significant (P >.05). CONCLUSIONS: Our results suggest that (1) glenohumeral stiffness is widely distributed in healthy shoulders, (2) glenohumeral stiffness is not significantly different between men and women, and (3) glenohumeral stiffness is not significantly different among directions of translations.

In vivo quantification of capsular end-point in the nonimpaired glenohumeral joint using an instrumented measurement system

STUDY DESIGN

Single-group factorial.

OBJECTIVES

Quantify glenohumeral joint translations as a function of force using an instrumented measurement system. Our first specific aim was to compare the magnitude of force (N) required to reach capsular end-point between the anterior, posterior, and inferior directions. Our second specific aim was to compare the magnitude of translation (mm) at capsular end-point between the anterior, posterior, and inferior directions.

BACKGROUND

Manual force-displacement techniques are subjective in nature, and the clinician must rely on "feel" to determine capsular end-point. Several investigators have attempted to utilize more objective measures at the glenohumeral joint, however none have quantified the force or displacements necessary to achieve a true capsular end-point.

METHODS AND MEASURES

An arthrometric technique was used to measure anterior, posterior, and inferior glenohumeral translations in 20 nonimpaired shoulders (11 women and 9 men with a mean age of 20.9 +/- 3.6 years).

RESULTS

The magnitude of applied force required to reach capsular end-point was significantly different between directions of translations. Anterior-directed translations required a significantly greater magnitude of applied force to reach capsular end-point than inferior-directed translations. The magnitude of translation was not significantly different between directions at capsular end-point.

CONCLUSIONS

Applied forces in the range of 181 to 203 N are necessary to reach capsular end-point in subjects with nonimpaired shoulders. Anterior translation required significantly higher forces (203.1 +/- 13.1 N) to reach capsular end-point than inferior translation (181.4 +/- 31.9 N).

Instrumented measurement of glenohumeral joint laxity: reliability and normative data

This study assessed shoulder laxity using an instrumented arthrometer. We compared anterior and posterior translations at various force levels to determine the reliability of our measurement technique and to provide normative data in healthy shoulders. Fifty shoulders were assessed for glenohumeral joint laxity in two directions (anterior and posterior) and at four force levels (67, 89, 111, and 134 N). The dependent measure was joint displacement. Laxity values were widely, yet normally, distributed in our group of healthy shoulders. Intraclass correlation coefficients revealed excellent between-trial reliability (0.92) and fair between-session (0.73) and between-examiner (0.74) reliability. The average standard error of measurement between trials (0.56 mm), sessions (1.5 mm), and examiners (1.7 mm) demonstrated an unprecedentedly high degree of precision for quantifying glenohumeral joint laxity. Paired t tests revealed no significant laxity differences between sides (P>0.05), indicating bilateral symmetry. A 2 (direction) x 4 (force) analysis of variance revealed significant differences in laxity between directions (P<0.0001) and force levels (P<0.0001). Our results show that our instrumented technique for quantifying glenohumeral joint laxity is precise and reproducible. Posterior translation was significantly greater than anterior, and a significant increase in translation was observed between increasing levels of force.

Instrumented measurement of glenohumeral joint laxity and its relationship to passive range of motion and generalized joint laxity

The purpose of this study was to objectively characterize in vivo glenohumeral joint laxity using an instrumented shoulder arthrometer. Secondary objectives were to examine the relationship of glenohumeral joint laxity with passive range of motion and generalized joint laxity. Fifty-one recreational athletes with no history of shoulder injury or long-term participation in overhead sports participated in this study. Anterior and posterior laxity data were obtained at displacement forces of 67, 89, 111, and 134 N. Bilateral passive shoulder range of motion measures were obtained, and a modified Beighton Mobility Score was used to quantify generalized joint laxity. There were no significant differences in glenohumeral joint laxity between the right and left shoulders (P values = 0.14 to 0.73). No significant differences in laxity were seen between directions (F(1,400) = 1.35, P = 0.25). However, significant differences were observed between force levels (F(3,400) = 27.17, P < 0.0001). No moderate or stronger correlations between laxity, passive range of motion, and generalized joint laxity were seen. These data confirm the presence of a wide spectrum of symmetric laxity in subjects that fails to correlate strongly with passive range of motion or generalized joint laxity.

Patterns of glenohumeral joint laxity and stiffness in healthy men and women

PURPOSE

The purpose of this study was to identify gender-related differences in glenohumeral (GH) joint laxity, stiffness, and generalized joint hypermobility in healthy men and women.

METHODS

Fifty-one healthy men and women were tested for generalized joint hypermobility, and anterior-posterior (AP) joint laxity and stiffness using a single-group factorial design.

RESULTS

Women exhibited significantly more anterior joint laxity (men 8.3 +/- 2.2 mm vs women 11.4 +/- 2.8 mm, P < 0.001) and less anterior joint stiffness (men 20.5 +/- 5.0 N x mm(-1) vs women 16.3 +/- 4.2 N x mm(-1), P < 0.01) than men. Men had significantly more posterior joint laxity than anterior (Ant 8.3 +/- 2.2 mm vs Post 9.6 +/- 2.9 mm; P < 0.001), and women also had significantly less anterior joint stiffness than posterior [Ant 16.3 +/- 4.2 N x mm(-1) vs Post 22.1 +/- 6.9 N x mm(-1); P < 0.01], Women also demonstrated significantly more generalized joint hypermobility than men (men 1.0 +/- 1.7 vs women 2.9 +/- 2.1; P = 0.02).

CONCLUSIONS

Our findings may indicate a possible increased risk for instability in women, especially those participating in sports that require repetitive overhead-throwing motion. Future investigations should seek to determine the contribution of increased GH joint laxity and decreased joint stiffness to various injury states and examine these variables in other populations such as overhead-throwing athletes.

The importance of gender on myokinetic deficits before and after microinjury

PURPOSE

The purpose of this study was to determine the importance of gender on myokinetic deficits before and after muscle microinjury.

METHODS

A repeated measures design assessed selected muscle force production characteristics in 20 male and 25 female volunteers. Peak force production (PFP) and the peak rate of force production (PRFP) were assessed before and over a 4-d period after an induced muscle microinjury.

RESULTS

ANOVA revealed statistically significant mean (+/-SD) differences between men and women for PFP and PRFP (P < 0.0001). Both genders demonstrated significant between-day differences for PFP (P < 0.016), whereas only men demonstrated significant between-day differences for PRFP (P < 0.016).

CONCLUSIONS

Our results reveal that muscle force generating capabilities of physically active men exceed that of women both before and after microinjury. Myokinetic deficits were most pronounced acutely, between 24 and 48 h postinjury, followed by a near complete recovery at day 4 (96 h postinjury). Both genders suffered acute and residual deficits for PFP, whereas only men showed significant acute deficits for PRFP. We recommend that athletes, both male and female, refrain from strenuous exercise at least 48 h postinjury, or until force-generating capabilities normalize. More research needs to be conducted to substantiate these findings.