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 TrainingDirector, Athletic Training Practice-Based Research Network

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

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)

Physical and psychosocial

benefits

Sport-related injury

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

ICF Framework

Snyder, JAT, 2008

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)

Health-Related Quality of Life

Physiologic

Economic

Spiritual Social

Physical

Psychological

Whole Person Healthcare

Whole Person

Healthcare

Health and illness

involve the whole person

Patient is central

Narrative health history

Integrated healthcare

team

ICF Framework

Snyder, JAT, 2008

Why Measure HRQOL?

Policy focusedHealthcare

System• Comparative Effectiveness Research (Sauers, 2012)

• Facilitate Evidence-Based Practice (Valovich McLeod, 2008)

• Common Language (NINDS CDEs; PCORI)

Patient-focusedClinical

• Unique accounting of health status• Different reactions to the same condition (Gyatt, 1993)

• Comprehensive health indicator (Schipper, 1996)

• Subjective and objective (Zullig, 2005)

• 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

interventionswww.atpbrn.org

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

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?

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 reliabilityand excellent internal consistency of the Pedi-IKDC (Kocher, 2010)

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 well-being 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

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

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)

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 than the physical Valovich McLeod et al. Athl Train Sports Health, 2010

Valovich McLeod et al. Brain Injury, 2010

What is the Impact of Prior Concussions on HRQOL?

• Collegiate athletes• 3+ previous

concussions result in lower HRQOL– Bodily pain– Vitality– Social functioning– Headache

36

41

46

51

56

61

66

71

76

0 SRC 1-2 SRC 3+ SRC

HIT

-6 T

otal

Sco

re

* *

Kuehl et al. Clin J Sport Med. 2010

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)

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

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)

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

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)

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?

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

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.”

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.”

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.”

Familial Experience Following Sport-Related Concussion

• Semi-structured interviews with concussed athletes held out of play >10d and their parent(s)

Isolation

Minimization and

Masking

Emotional Slippage

Parsons & Valovich McLeod: Brain Inj, 2012 (abstract)

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)

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 HRQOLParsons, J Athl Train, 2012 (abstract)

Accommodation Type

Parsons, J Athl Train 2012

w/ Accommodation…

Parsons, J Athl Train 2012

⬆ Total Days of Missed School

⬇ D3, Physical Functioning

⬇ Pyschosocial Functioning

⬇ School Functioning

⬇ D3, PedsQL Total Score

⬆ D30 HIT6 Total Score

w/ Absence…

Parsons, J Athl Train 2012

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

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

PROs are reliable and valid for use with adolescent athletes

Adolescent athletes differ from non-athletes 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

Stovitz, BJSM, 2010

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

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

www.atsuconcussion.com

tmcleod@atsu.edu

480-219-6035

www.atpbrn.org