Patient-Reported Outcome Measures in Sports Medicine: A Concise Resource for Clinicians and Researchers

In aligning itself with global health care initiatives,^1–5 the athletic training profession has made focused efforts to foster the assessment of clinical outcomes, particularly patient-reported outcomes, during routine patient care.^6–8 For example, the athletic training profession has highlighted the need to assess patient-reported outcomes in the current editions of the Athletic Training Education Competencies⁹ and the Role Delineation Study,¹⁰ as well as the 2020 Standards for Accreditation of Professional Athletic Training Programs.¹¹ Furthermore, the National Athletic Trainers' Association has recently adopted the use of the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework, highlighting the need for athletic trainers (ATs) to view patients from a whole-person perspective.¹² These foundational documents in athletic training emphasize not only the need for clinical outcomes assessment during patient care but also the important role patient-reported outcome measures (PROMs) play in capturing the patient's perspective, informing patient care decisions, and evaluating the effectiveness of treatment approaches from a whole-person perspective.^4–6,13

Although the importance of assessing patient outcomes and the use of PROMs is clear, current evidence suggests only 15% to 26% of ATs routinely use PROMs during patient care.^14–16 When asked to identify barriers to the routine use of PROMs during patient care, ATs who did not use PROMs reported that the lack of education about and understanding of PROMs impeded their ability to successfully implement PROMs in their clinical practice.^14–16 Recent findings¹⁷ indicated that the vast majority of ATs (68%–98%) were unfamiliar with PROMs that were frequently reported in the athletic training literature, including the Foot and Ankle Ability Measure (FAAM; 82.1% of the sample was unfamiliar), the Medical Outcomes Study 36-Item Short Form Health Survey (86.2% were unfamiliar), and the Patient-Specific Functional Scale (PSFS; 82.1% were unfamiliar), further underscoring this lack of knowledge. Although a general lack of knowledge of and inexperience with PROMs are not unique to the athletic training profession,¹⁸ these barriers can negatively affect the comprehensive implementation of PROMs during patient care, particularly during the intricate process of selecting the most appropriate instrument among the numerous available PROMs.

To help ATs evaluate the available PROMs and identify the most appropriate instruments for use in patient care, Snyder Valier and Lam¹⁹ provided a detailed summary of the major considerations related to PROM selection. In short, ATs should consider both the instrument essentials (ie, instrument development, reliability, validity, responsiveness and interpretability, and precision) and the clinical utility (ie, acceptability, feasibility, and appropriateness) of the instrument.¹⁹ Furthermore, when assessing the appropriateness of a PROM, ATs were advised¹⁹ to consider the health domains represented in disablement models²⁰ and dimensions of health-related quality of life (HRQOL)^21,22 captured by the instrument to ensure that the PROM can support patient-centered care. Because of busy athletic training clinicians' lack of time and resources,^14,15,18 gathering and evaluating all the information related to the instrument essentials and clinical utility for numerous PROMs is challenging. Although previous authors have reviewed the use of PROMs in the sports medicine community, these commentaries have generally reviewed PROMs from the perspectives of orthopaedic surgeons, whose patient population may not necessarily reflect the young and highly functional patient population for whom ATs usually provide care^23–25 or may not have reviewed a comprehensive list of PROMs reported by ATs who routinely use them.²⁶ In addition, these researchers did not critically review instruments based on the health domains represented in disablement models or dimension of HRQOL, which are important components to patient-centered, whole-person care. Therefore, the purpose of our report was to critically review the instrument essentials and clinical utility of the PROMs reported by ATs who used PROMs to (1) provide a helpful and concise guide for ATs to refer to during the PROM selection process and (2) facilitate the use of PROMs in athletic training clinical practice.

METHODS

KEY FINDINGS

Based on the findings of Lam et al,¹⁵ a total of 17 region-specific, 6 generic, and 3 single-item PROMs were endorsed by at least 10% of the ATs who used PROMs and thus were reviewed for this report. For region-specific PROMs, 11 lower extremity–specific (3 foot and ankle, 3 knee, 3 hip, 2 back) and 10 upper extremity–specific (3 shoulder-elbow, 3 wrist-hand, 1 neck, 3 head) instruments were studied (Table 1). Four PROMs were identified for use in multiple body regions: the Lower Extremity Functional Scale (knee and hip), Disabilities of the Arm, Shoulder and Hand (DASH; wrist-hand and shoulder-elbow), Quick-DASH (wrist-hand and shoulder-elbow), and Upper Extremity Functional Scale (wrist-hand and shoulder-elbow).

Table 1 Concise Summary of Included Patient-Reported Outcome Measures

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As a result, a total of 26 unique PROMs (10 lower extremity region specific, 7 upper extremity region specific, 6 generic, and 3 single item) were evaluated in this review. Consistent with Lam et al,¹⁵ we classified the PSFS as a single-item measure because it is neither a specific nor a generic measure. Table 1 provides a general summary of the instrument essentials and clinical utility of each included PROM for quick reference. More detailed summaries of the instrument essentials, including specific measurement property values, of lower extremity–specific, upper extremity–specific, and generic and single-item measures can be found in Tables 2, 3, and 4, respectively. Summaries of considerations for clinical utility can be found in Tables 5, 6, and 7.

Table 2 Lower Extremity Patient-Reported Outcome Measures: Essential Elements

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Table 3 Upper Extremity Patient-Reported Outcome Measures: Essential Elements

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Table 4 Generic and Single-Item Patient-Reported Outcome Measures: Essential Elements

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Table 5 Lower Extremity (LE) Patient-Reported Outcome Measures: Considerations for Clinical Utility Extended on Next Page

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Table 5 Extended From Previous Page

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Table 6 Upper Extremity (UE) Patient-Reported Outcome Measures: Considerations for Clinical Utility Continued on Next Page

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Table 7 Generic and Single-Item Patient-Reported Outcome Measures: Considerations for Clinical Utility Extended on Next Page

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Table 7 Extended From Previous Page

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COMMENTARY

To our knowledge, this is the first report to critically review and summarize the instrument essentials and clinical utility of generic, specific, and single-item PROMs that are used in athletic health care. In addition, we provided a summary of the ICF health domains and HRQOL dimensions that questions within each PROM addressed to offer insight into their use when delivering patient-centered care. Overall, we aimed to provide a helpful, concise resource for ATs to consult when selecting and implementing PROMs.

In general, the PROMs studied in this commentary demonstrated appropriate instrument essentials, with almost all having a systematic development process and acceptable psychometric properties including reliability, validity, and responsiveness. However, it is important to note that only a few of the instruments were specifically designed to evaluate aspects of disablement and health among highly functional patients, such as athletes. For example, of the instruments reviewed, only the DPA^77,78 and the Abbreviated Profile of Mood States⁷⁴ were developed with athletes as the intended population. Further, much of the research to date related to the instrument measurement properties of generic, specific, and single-item PROMs has been conducted in populations other than a highly functional patient population such as athletes. This finding is a concern when considering the validity of the instruments for use in athletic health care.

Other PROMs were designed for the athletic population, such as the Kerlan-Jobe Orthopaedic Clinic overhead athlete score,¹⁴² the Functional Arm Scale for Throwers,^143,144 the Athlete Fear Avoidance Questionnaire,¹⁴⁵ and the Swimmer's Functional Pain Scale.¹⁴⁶ Yet previous research¹⁵ indicated that fewer than 10% of ATs routinely used these instruments. Thus, they were not included in this report. However, even though many of the included PROMs were developed for more general populations, these patients often presented with injuries similar to those sustained by athletes.^35,53 Ideally, measurement properties such as reliability, validity, and responsiveness should be established for the intended population.¹⁹ Because evidence^147–149 suggested that the HRQOL of highly functional patients is different than that of the general population, future work is needed to establish the validity, reliability, and responsiveness of the PROMs most commonly used in athletes.

The PROMs included in this report appear appropriate, acceptable, and feasible for use in athletic health care. Considering readability specifically, the general guidance was that the calculated reading grade level be 2 reading levels below a patient's actual grade level.^27,28 For example, a patient in the ninth grade should be administered a PROM with a reading level of seventh grade or lower. Of the reviewed PROMs, the vast majority (20 of 26, 76.2%) had an estimated reading level of seventh grade or lower, suggesting that they would likely be appropriate for adult and adolescent patients. However, it is important to note that a patient's grade level may not necessarily align with his or her actual reading level (eg, students of English as a second language); clinicians should take this into account when selecting a PROM.

When we assessed the ICF health domains and HRQOL dimensions of health captured by the reviewed PROMs, it was not surprising that many of the instruments emphasized specific aspects of health. Most instruments include questions that evaluate the ICF health domains of body structure and function and the HRQOL dimensions of physiological and physical functioning. For example, the Lower Extremity Functional Scale and the FAAM are region-specific PROMs that focus solely on functional ability. Using PROMs that evaluate physical function in athletic health care is appropriate because highly functional patients often focus on maintaining or regaining high levels of physical function to perform activities in daily life and sports. For example, a common goal of athletes is to restore function to compete in their sports and fulfill their role as an athlete. Instruments that evaluate function allow ATs to better direct rehabilitation to meet these performance and role goals (ie, participation domain of the ICF). Even though regaining function is a common goal of athletes, other ICF health domains and HRQOL dimensions may warrant attention.¹⁹

Information related to body structures and functions, such as range of motion and strength, is helpful for clinicians to obtain a more complete understanding of the status of tissue healing, which may support treatment decisions to promote continued recovery.²⁰ An equally important area of health to evaluate is participation. However, the participation domain was not a frequent component of the PROMs included in this review. Participation reflects the areas of health that many patients care most about because it relates to the ability to complete necessary or desired life roles, such as athlete, friend, student, parent, or employee.²⁰ When selecting PROMs, ATs should consider whether the patient case warrants evaluation of the participation domain, particularly because athletes often have a strong identity grounded in being an athlete. The effect of identity loss due to injury and removal from sport may be an important focus when managing and coordinating care for a patient. In general, generic instruments include more questions that capture participation than specific instruments because they are designed to assess health on a more global level. However, some of the region-specific measures, such as the DASH,⁵³ the Dizziness Handicap Inventory,⁷⁵ and the Low Back Outcome Score,⁴⁶ do contain several questions related to the participation domain and may be considered depending on the region of the patient's injury.

Consider, for example, the care of a patient with an ankle sprain. The FAAM may be the PROM that a clinician identifies for use based on the fit of the instrument to the region of interest, instrument essentials, and patient friendliness. However, one consideration is that the FAAM is largely focused on functional ability.³¹ If the AT is approaching care from a patient-centered, whole-person perspective, coupling the FAAM with additional PROMs may be necessary, as the FAAM may evaluate only a limited scope of the HRQOL dimensions affected by an injury. A generic instrument (eg, Pediatric Quality of Life, DPA) could be considered depending on the HRQOL dimensions most relevant to the patient. In a recent case report, Fraser and Hertel¹⁵⁰ described the effect of a lateral ankle sprain on comprehensive function, HRQOL, and kinesiophobia. Through their use of multiple PROMs (ie, Godin Leisure-Time Exercise questionnaire, FAAM, Identification of Functional Ankle Instability, Tampa Scale of Kinesiophobia, Patient-Reported Outcomes Measurement Information System, EuroQoL), the authors were able to capture postinjury deficits across multiple ICF health domains and HRQOL dimensions and comprehensively manage the rehabilitation process while considering the patient's perspective via PROMs. In this case report,¹⁵⁰ they used many instruments, which may be unrealistic for everyday patient care. However, the diversity of these instruments provided the clinicians with unique information that helped drive treatment and emphasized patient-centered care. This example shows that whereas most of the PROMs are valid for use in managing patient care, patient goals and case details (eg, ICF health domains, health dimensions) may be strong factors influencing instrument selection.¹⁹

Of the PROMs reviewed, the MFA and Short MFA appeared to possess challenges for use in some patient groups related to athletic training. These instruments were originally developed^79,81 to assess musculoskeletal disorders in patients within the community and academic settings, which may limit their appropriateness for the athletic population. Although these scales are attractive because of their applicability to patients with a wide variety of musculoskeletal conditions,^79,81 their long length, due to the inclusion of questions that pertain to functioning over the entire body, makes them less patient (eg, completion time, survey fatigue) and clinician (eg, time required to score) friendly. Further, specific questions may be considered unacceptable for some patients because of their sensitive nature (eg, items related to sexual functioning). Based on previous findings,¹⁵ the MFA and Short MFA were used by ATs, albeit at relatively low percentages (10.9% for the MFA and 13.5% for the Short MFA). In some athletic training facilities, the MFA and Short MFA may be appropriate because of factors such as patient demographics (eg, age) or greater ability and organizational support to complete longer PROMs, although an instrument that is more focused on the body region of interest may provide a similar assessment in a shorter amount of time. Nonetheless, ATs interested in using the MFA or Short MFA should be aware of these factors when deciding if these instruments are appropriate and if they fit the intended use in the target patient population.

Time is the primary factor that influences whether clinicians implement PROMs.^14,15 In addition, the reality is that many ATs are relatively new to the assessment of patient outcomes as a routine component of care.^14,15 One type of PROM that may be appealing for clinicians who are beginning to implement outcomes assessment into care is the single-item instrument. Single-item instruments are arguably the easiest to incorporate into patient care because they consist of 1 question and take little time to administer, complete, and score. As a result, these measures are very patient and clinician friendly. Although single-item PROMs provide a quick glimpse of health in a short amount of time, these measures have limitations. Single-item PROMs do not provide as much information related to any specific ICF health domain or HRQOL dimension as multi-item measures. Also, the wording of some single-item instruments is vague and refers to health status or injury or illness in general and not specifically to characteristics such as pain or function. Thus, the exact aspect of health that the patient is reflecting upon when completing some single-item PROMs is unknown.¹⁰⁰ For example, the GROC instrument asks patients to compare their health between one point in time and another.¹⁰⁰ Not only does the GROC question ask patients to calculate a difference between time points, the health construct focused on by the patient could be related to a number of different aspects of health (eg, pain, function, ability to complete roles).¹⁰⁰ In addition, clinicians should consider whether an instrument has been modified from its original version and if those modifications are psychometrically sound. The GROC was originally developed as a 15-point scale;¹⁰¹ however, modifications (eg, 11-point,¹⁵¹ 9-point,¹³³ 7-point,¹⁴⁴ and 5-point¹⁵² scales) are available. The abbreviated versions are frequently incorporated into patient care and used in research studies, yet limited information exists regarding their development. Athletic trainers should consider the use of single-item PROMs in practice because of their versatility and ease of use, and these instruments are helpful when an AT is starting to include outcomes assessment as a routine part of patient care. However, ATs should also be aware that the brevity of these instruments results in less information gained about the patient and the health condition than from multi-item measures.

A limitation of our report is that not all of the instruments used in athletic health care were included in this review. In an effort to report on instruments used in athletic training, investigators¹⁵ conducted survey research to identify the PROMs used most often by ATs. Although we believe that the PROMs reviewed in this report have the potential to support athletic health care and are commonly used in practice, there are likely other instruments with which ATs should be familiar. Furthermore, the landscape of PROM use in athletic training is ever changing. Thus, newer instruments developed in recent years may not have been reviewed in this report. Despite these limitations, we believe that our concise summary of PROMs used by ATs is a helpful resource for the profession as a whole, given ATs' relatively low use of and general lack of knowledge regarding PROMs, which appear to hinder the overall use of PROMs in athletic health care.

CONCLUSIONS

In general, the PROMs included in this report possess established and appropriate instrument essentials and clinical utility, supporting their use in patient care. With respect to the ICF health domains and HRQOL dimensions of health, the included PROMs generally focus on body structure and function as well as the physical functioning of the patient. Although that focus is not surprising and is typically helpful in caring for athletes, a sole focus on these components does not comprehensively capture the patient from a whole-person perspective. Thus, ATs with the primary goal of evaluating each patient as a whole person to support patient-centered care should consider a collection of PROMs as opposed to a single instrument. Efforts to make the use of PROMs in athletic training more routine will likely result in the development of new PROMs that are designed specifically for highly functional patients. As a result, in addition to considering the PROMs included in this report, ATs should stay abreast of newly developed PROMs.