Tamara Valovich McLeod, Ph.D. - "The Impact of Sport-Related Injury on Health-Related Quality of Life"


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The Youth-Nex Conference on Physical Health and Well-Being for Youth, Oct 10 & 11, 2013, University of Virginia

Tamara Valovich McLeod, Ph.D. - "The Impact of Sport-Related Injury on Health-Related Quality of Life"

Valovich McLeod is the John P. Wood, D.O., Endowed Chair for Sports Medicine and a Professor in the Athletic Training Program at A.T. Still University.

Panel 5 -- Injury Prevention and Treatment. While being physically active is important for positive youth development, injuries can result. This panel will discuss ways to minimize injury, particularly concussions, while addressing the impact of sport-related injury on quality of life. The panel will also provide a blueprint for encouraging life-long physical activity.

Website: http://bit.ly/YNCONF13

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  • Check title – check time of talk – check on academic accommodations
  • Global concept that takes into account the physical, psychological, and social domains of health (Testa, NEJM, 1996)Considers the whole-personAddresses disabilities and societal limitationsSelf-esteem, academic interactions and sport participation are significantly impacted by chronic conditions (Vitulano et al, 2003)
  • Integrated healthcare team – AT, directing physician, vestibular therapy, academic counselors, other HCPs
  • Unique accounting of health in lifeDifferent reactions to same condition (Guyatt et al., 1993)Comprehensive health indicator (Schipper et al., 1996)Subjective & Objective (Zullig et al., 2005)
  • 1) patient-based outcomes scales are reliable and valid for use in the adolescent athletic population,68, 78-802) adolescent athletes differ from non-athlete peers on measures of HRQOL,813) athletes with a positive history of injury report lower HRQOL compared to athletes with a negative injury history,59, 68-70, 80, 824) present ratings of pain in athletes fully participating in sport negatively influences self-reported HRQOL,68, 80 and 5) adolescent athletes who suffer a sport-related injury demonstrate a lower HRQOL compared to population normative means.83
  • consistent findings across a relatively large sample of adolescent athletes from multiple sports with a variety of injury types at various regions.
  • Athletes with ACL injuries reported over seven times more depression 11 days post-injury than at baseline. In contrast, 4 days post-injury concussed athletes showed elevated depression scores three times greater than scores at baseline, but the elevations resolved 1 week after injury.NEED TO THINK ABOUT MORE THAN JUST RTP!!!
  • Overall emotional disturbance and depression seen in the first week post-concussion in the study mirrors the neurocognitive changes identified in many other concussion studies[41–48]. These transient changes in cognitive and emotional functioning seem to reflect athletes ’feelings of being ‘off’ or in a ‘fog’[49] and it is speculated that they resonate with the transient neurochemical cascade [50–52] and physiologic disturbances.
  • These findings highlight the need for clinicians, administrators and teachers to consider the potentially negative academic consequences of SRC.
  • In-depth, semi-structured interviews were completed with 13 adolescent athletes whose injury causes them to miss 10 or more consecutive days of competitive athletics. Interview questions mirrored the established factor structure of the SF-36, a health-related quality of life instruments employed elsewhere in this project. The interview questions were piloted on 2 participants, which lead to only minor modifications in question sequencing. Informed consent forms were collected and semi-structured interviews were conducted with these participants.
  • Isolation: SRC disembeds patients from the routines of all aspects of their life. This produces strong feelings of isolation, and to some degree confusion, on behalf of the patient. Interestingly, this isolation is often necessary for, and a byproduct of, the recovery process, but is perceived different by patient and by family To patients, the isolation is often perceived as a misunderstanding by others about the nature of his or her experience:…Because maybe some people think I’m fine. Really, they don’t know what I’m going through and they don’t know what’s wrong with me. To family, the isolation is often perceived as a decrease in motivation:…this kid, before this concussion every single night even in the summer months when it was 110 would go out for a jog, every night. He’d work at it, he sit here and do sit-up after sit-up, push up push up, on and on and he doesn’t do that. You know, he’s just – it’s like his motivation is gone….Before it was so important for him to always be with people – be with a friend or whatever…He’s just fine just doing nothing. Minimization and Masking: In turn, patients seek to minimize and mask their condition in an attempt to limit further isolation:I do feel like I’m all right, but people tell me that I’m not all right. So, I kind of feel both ways sometimes. Because I feel like I should be playing and I don’t really, I’m not really scared of having a concussion and I think that I’m all right, but, I mean my parents have noticed stuff about me that I haven’t really noticed and they’ve said some things to me so . . .Emotional Slippage: However, the emotional and personality changes symptomatic of their injury reveal them: I mean, he’ll be sitting on the couch, watching a movie and in the middle of it, he can’t sit anymore, gets up and does weird stuff. I mean, like gets up and starts being weird for 10 minutes and then sits down and is wiped out. It’s not normally him.
  • And one area where we see this tension is returning to the classroom
  • Frequency of school absence and academic accommodation, accommodation type, and relationship to both clinical and patient-centered outcomes measuresSchool absence and accommodations data were collected for 144 patients: 27.8% (n=40) missed school, and 16% (n=23) received academic accommodations because of concussion. Accommodation types received: shorter day [n=9(5.3%)]; other [n=7(4.1%)]; rest breaks [n=5(2.9%)]; note taker [n=5(2.9%)]; [n=5(2.9%)]; less homework [n=3(1.8%)]; individualized learning plan [n=2(1.2%)]; special permissions shorter classes [n=1(0.6%)]. For those requiring accommodations, Mann-Whitney U tests revealed significant differences (P<.05) in: number of school days missed; D3 PF, PSF, and SFS, and PedsQL total score; D10 HIT6 total score; D30 HIT6 total score. For those with school absences, Mann-Whitney U tests revealed significant difference in: DOI balance, feelings of slowness, feeling fatigue, confusion, drowsiness, sleep problems, irritability, total symptom severity and endorsements (all p<.05), and DOI SCAT2 total score (p<.01); D3 PFS (p<.01), SFS (p=.001), PedsQL total score (p<.05), and SLF (p<.05); D10 HIT6 total (p<.05)
  • N=23 those who received accommodationsDoesn’t add up because patient could have MORE THAN ONE
  • Those with accommodations
  • National survey to 3,286782 useable responses ~23.8% response rate (acceptable)
  • 1) patient-based outcomes scales are reliable and valid for use in the adolescent athletic population,68, 78-802) adolescent athletes differ from non-athlete peers on measures of HRQOL,813) athletes with a positive history of injury report lower HRQOL compared to athletes with a negative injury history,59, 68-70, 80, 824) present ratings of pain in athletes fully participating in sport negatively influences self-reported HRQOL,68, 80 and 5) adolescent athletes who suffer a sport-related injury demonstrate a lower HRQOL compared to population normative means.83
  • Tamara Valovich McLeod, Ph.D. - "The Impact of Sport-Related Injury on Health-Related Quality of Life"

    1. 1. The Impact of Sport-Related Injury on Health-Related Quality of Life Tamara C. Valovich McLeod, PhD, ATC, FNATA John P. Wood, D.O., Endowed Chair for Sports Medicine Professor, Athletic Training Director, Athletic Training Practice-Based Research Network
    2. 2. Objectives 1. Define health-related quality of life (HRQOL) 2. Discuss the HRQOL of adolescent athletes 3. Describe how sport-related injury effects HRQOL 4. Describe the impact of concussion on HRQOL
    3. 3. Adolescent Athletics • Over 30 million children and adolescents participating in organized sports (Hergenroeder, Pediatr, 1998) • More than 7.6 million high school students participating in interscholastic athletics (NFHS, 2011-12 Participation Survey)
    4. 4. Physical and Sport-related psychosocial injury benefits
    5. 5. Pediatric Sport-Related Injury • >3 million injuries annually that cause time lost from organized sport (Hergenroeder, 1998) – More than 35% of all medical visits in 5-17 year olds and – More than 20% of all emergency department visits in 5-24 year olds – Estimated cost (1996) of these visits was over $1.3 billion annually • 12 million student athletes between the ages of 5-22 will suffer a sports related injury this year (Janda, 2004) – Resulting in 20 million lost days of school
    6. 6. ICF Framework Snyder, JAT, 2008
    7. 7. Impact of Sport-Related Injury • Financial impact – 10 million pediatric primary care office visits (Hambidge, Pediatr, 2002) – 4.3 million estimated ER visits (Burt, Ann Am Med, 2001) – $33 billion annually in health care costs (Orthop Today, 2002) • Impact on individual athlete – Physical injury – Psychosocial effects – Health-related quality of life (Snyder, JAT, 2008; Valovich McLeod, JAT, 2008)
    8. 8. Health-Related Quality of Life Physical Social Spiritual Economic Physiologic Psychological
    9. 9. Whole Person Healthcare Patient is central Health and illness involve the whole person Narrative health history Whole Person Healthcare Integrated healthcare team
    10. 10. ICF Framework Snyder, JAT, 2008
    11. 11. Why Measure HRQOL? Healthcare Policy focused System • Comparative Effectiveness Research (Sauers, 2012) • Facilitate Evidence-Based Practice (Valovich McLeod, 2008) • Common Language (NINDS CDEs; PCORI) Clinical • • • • Patient-focused Unique accounting of health status Different reactions to the same condition (Gyatt, 1993) Comprehensive health indicator (Schipper, 1996) Subjective and objective (Zullig, 2005)
    12. 12. • The mission of the Athletic Training PBRN is to improve the quality of care and patient outcomes in patients under the care of certified athletic trainers. – Address current issues in athletic training – Identify the patient perspective in athletic healthcare – Identify effective and cost-efficient treatment interventions www.atpbrn.org
    13. 13. Adolescent HRQOL • Cannot be judged by the same criteria as adults – Revolves specifically around school, extra-curricular activities, social interactions and family life (Hershey, 2001) – Self-esteem, academic interactions and sport participation have are significantly impacted by chronic conditions (Vitulano, 2003) • Need population- specific outcomes instruments
    14. 14. Can adolescent athletes reliably report HRQOL? Do adolescent athletes differ in HRQOL compared to non-athletes? Does prior injury history influence HRQOL? How does sport-related injury effect impact HRQOL? What meaning does injury have for adolescent athletes?
    15. 15. Can Adolescents Reliably Report HRQOL? • Reliable at reporting concussion-related symptoms (Mailer, 2008) • Reliable at reporting upper extremity HRQOL using the Functional Arm Scale for Throwers (FAST) (Sauers, 2011) • Acceptable test-retest reliability and excellent internal consistency of the Pedi-IKDC (Kocher, 2010)
    16. 16. Do Athletes Report Different HRQOL Compared to Non-Athlete Peers? • Athletes reported higher HRQOL than non-athletes (Snyder, 2010) – Subscales related to mental, emotional, and physical wellbeing when compared to non-athletes • Athletes report better HRQOL than healthy adolescent peers (Lam, 2013) – Particularly in emotional functioning – Appear to be a unique population and specific normative data should be established • Suggest that athletic involvement is a benefit to the overall health status of adolescents
    17. 17. Do Male and Female Adolescent Athletes Differ with Respect to HRQOL? • Differences were noted in psychological aspects of HRQOL (Tanabe, 2010) – Males reported higher psychological well-being than females (VT, MCS) • Males reported higher HRQOL on all PedsQL subscales, except social functioning (Lam, 2013) • Suggest that gender differences should be considered during injury evaluation and management
    18. 18. Does Prior Injury History Influence HRQOL? • Lower HRQOL in throwing athletes (Sauers, 2011; Huxel, 2010) – History of an arm or shoulder pitching-related injury that restricted participation in pitching for one week (r=.46-.70) – Seeing a physician for a pitching-related injury that restricted participation in pitching for one week or more (r=.50-.99) – Having surgery on the arm or shoulder from a pitching-related injury (r=.50-.99)
    19. 19. Does Concussion History Influence HRQOL? • + concussion history reported lower HRQOL – SF-36: bodily pain, general health, vitality, mental health – PedsQL: physical, emotional, school functioning – MFS: general, sleep, cognitive fatigue – HIT-6: total score – GSS: total symptom score • Impacts the emotional aspects of HRQOL more Valovich McLeod et al. Athl Train Sports Health, 2010 than the physical Valovich McLeod et al. Brain Injury, 2010
    20. 20. What is the Impact of Prior Concussions on HRQOL? 76 71 HIT-6 Total Score 66 0 SRC 1-2 SRC 3+ SRC 61 56 * 51 46 41 36 * • Collegiate athletes • 3+ previous concussions result in lower HRQOL – – – – Bodily pain Vitality Social functioning Headache Kuehl et al. Clin J Sport Med. 2010
    21. 21. How Does Recent Sport-Related Injury Affect HRQOL? • Adolescents with a self-reported recent injury demonstrated lower HRQOL compared to their uninjured peers – – – – Physical functioning Pain Social functioning Global HRQOL • Indicate injuries affect areas outside the expected physical component of health (Valovich McLeod, J Athl Train. 2009)
    22. 22. Knee Function and HRQOL After Knee Injury • Female adolescent athletes using the IKDC and SF-12 pre- and post-injury • IKDC scores lower after injury • SF-12 subscale and composite scores were all significantly lower following injury McGuine, 2012
    23. 23. Emotional Response Following Sport-Concussion • Increase in depression, confusion and total mood disturbance within the first 3 weeks following a concussion (Mainwaring, J Sport Ex Psychol, 2004) • Increased fatigue and decreased vigor when compared to athletes who suffered a musculoskeletal injury (Hutchison, CJSM, 2008) • Relative to controls, concussed athletes reported increased total mood disturbance and depression, but less depression than ACL injured (Mainwaring, Brain Inj, 2010) • Increased depression scores up to 14 days following concussion (Kontos, AMPR, 2012)
    24. 24. HRQOL Post-Concussion • Concussion acutely resulted in lower HRQOL – – – – Physical functioning Sleep fatigue Cognitive fatigue Impact of headache • Corroborate reports of post-concussion symptoms – BL: 9.8±9.8; DOI: 35.9±22.0; D3: 17.6±16.7 • Align with a time when athletes are often restricted from participating in physical and cognitive activities Valovich McLeod, J Athl Train, 2010
    25. 25. Impact of Time Loss on HRQOL • Time loss from sports participation is significantly associated with lower HRQOL • Strongest associations at Days 3 and 10 – When most athletes are withheld from competition and may still be experiencing symptoms • Time loss following a concussion was most strongly related to school functioning Valovich McLeod, IBIA, Brain Inj, 2012 (abstract)
    26. 26. What meaning does injury have for adolescent athletes? • Qualitative approach with injured adolescent athletes who are out of play for >10 days – What meaning do injured adolescent athletes attach to their injuries? – Do athletic injuries lead to HRQOL changes in adolescent athletes, and if so, why? – How do these injuries affect their perceived HRQOL?
    27. 27. Sport-Related Injury • Strong affective component • SRI represents a loss or challenge to the personal identity – Idea of “athlete” is a valued component of their identity – Loss of identity forces a difficult re-assessment and restructuring of their identity • Effects confidence, comfort level, and motivation
    28. 28. Injury Expectations • “I’ve always thought like it won’t happen. Like I’ve always seen people sitting out in the sideline, but it just seemed like too unimaginable because I’ve always, I don’t know, everyone’s just always told me how I was like the backbone and I would always would make like decisions for the team and I would always be like the one to like help out when we needed a helping hand, you know, play pull through, so it just seems like unimaginable for me to get hurt. It seriously wasn’t an option and I don’t know, now that I am it’s eye opening.”
    29. 29. Disruption of Social Network • “I think it just goes back to the fact that some people are more understanding than others. You know I’ve had some friends who will really be there for me and you know come see me after surgery or be willing to listen to how frustrated I am, even if I just wanna vent. But other people they just kinda move on since I can’t do the everyday things like I used to be able to do, they find someone else who can.”
    30. 30. Emotional Impact of Injury • “Anger, sadness, I can’t, it’s you know, I’ve cried a lot, it’s hard, I don’t, it’s hard to deal with. And it’s not always that tough and they know I can’t do a lot of stuff, and now, with my friends are now, but you know maybe just hanging out or seeing a movie is the better thing to do because I can do that and still spend time with them and be okay.”
    31. 31. Familial Experience Following Sport-Related Concussion • Semi-structured interviews with concussed athletes held out of play >10d and their parent(s) Isolation Emotional Slippage Minimization and Masking Parsons & Valovich McLeod: Brain Inj, 2012 (abstract)
    32. 32. Familial Experience Following Sport-Related Concussion • Parents are especially sensitive to accumulating performance deficits (e.g., school, physical) – Not as empathetic of the isolation and see it as a necessary side effect of therapeutic rest • Patients and their parents prioritize the effects of the injury differently = familial tension – Gradually resolves as both parties recognize the seriousness of the situation and as symptoms stabilize Parsons & Valovich McLeod: Brain Inj, 2012 (abstract)
    33. 33. Academic Accommodations • 144 adolescent patients • 27.8% (n=40) missed school – Higher DOI balance, feeling slow, fatigue, confusion, drowsiness, sleep troubles, irritability, TSS, TSE, and lower SCAT2 total – Lower D3 physical, school functioning, PedsQL total, sleep fatigue – Lower D10 headache-related HRQOL • 16% (n=23) received academic accommodations – Most common types were shorter day, rest breaks, note taker – Lower physical, psychosocial, and school functioning scores at D3 – Lower D10 & D30 headache-related HRQOL Parsons, J Athl Train, 2012 (abstract)
    34. 34. Accommodation Type Parsons, J Athl Train 2012
    35. 35. w/ Accommodation… ⬆ Total Days of Missed School ⬇ D3, Physical Functioning ⬇ Pyschosocial Functioning ⬇ School Functioning ⬇ D3, PedsQL Total Score ⬆ D30 HIT6 Total Score Parsons, J Athl Train 2012
    36. 36. w/ Absence… Parsons, J Athl Train 2012
    37. 37. Understanding Academic Accommodations • Beliefs, Attitudes, and Knowledge of Pediatric Athletes with Concussion (BAKPAC) – – – – Athletic Trainers Primary Care Providers School Nurses School Counselors Mayfield, RM, Unpublished Thesis, Presented at NATA 2013
    38. 38. Academic Decline • Have you personally encountered a situation where a student athlete that you have treated experienced a decrease in school and academic performance as a direct result of a symptomatic concussion? – Yes 79% (n=549) – No 21% (n=142) • ~44% of concussions resulted in some form of academic accommodations Mayfield, RM, Unpublished Thesis, Presented at NATA 2013
    39. 39. PROs are reliable and valid for use with adolescent athletes Adolescent athletes differ from nonathletes on HRQOL Athletes with + injury history report lower HRQOL Athletes who suffer an injury demonstrate lower HRQOL Sport-related injury significantly influences an adolescent's sense of self
    40. 40. Stovitz, BJSM, 2010
    41. 41. Take Home Points • Participation in sports results in better HRQOL in adolescents • Sport-related injury can negatively impact HRQOL – Prolonged symptoms and time loss are more likely to result in HRQOL deficits • HCPs need to be able to identify possible HRQOL issues and manage or refer – Need to consider aspects of rehabilitation other than the physical injury
    42. 42. Acknowledgements • AT-PBRN Leadership – – – – – – – – Eric Sauers, PhD, ATC, FNATA Alison Snyder, PhD, ATC John Parsons, PhD, ATC Kenneth Lam, ScD, ATC Bart Anderson, MS, ATC Kellie Huxel, PhD, ATC Curt Bay, PhD Cailee McCarty, PhD, ATC • Funding Agencies – ATSU Strategic Research Fund
    43. 43. www.atsuconcussion.com tmcleod@atsu.edu 480-219-6035 www.atpbrn.org