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1.  Patient-Reported Shoulder Outcome Measures Utilized in Breast Cancer Survivors: A Systematic Review 
Objective
1) To identify English Language published patient-reported upper extremity outcome measures used in breast cancer research and 2) To examine construct validity and responsiveness in patient-reported upper extremity outcome measures used in breast cancer research.
Data Sources
PubMed, CINAHL and ProQuest MEDLINE® databases were searched up to February 5, 2013.
Study Selection
Studies were included if a patient-reported upper extremity outcome measure was administered, the participants were diagnosed with breast cancer, and published in English.
Data Extraction
Eight hundred and sixty-five articles were screened. Fifty-nine full text articles were assessed for eligibility. A total of 46 articles met the initial eligibility criteria for aim 1. Eleven of these articles reported mean and standard deviations for the outcome scores, and included a comparison group analysis for aim 2.
Data Synthesis
Construct validity was evaluated by calculating effect sizes for known group differences in 6 studies using the Disabilities of Arm, Shoulder and Hand (DASH), Penn Shoulder Score, Shoulder Disability Questionnaire-Dutch, and 10 Questions by Wingate (Wingate). Responsiveness was analyzed comparing a treatment and control group by calculating the coefficient of responsiveness in 5 studies for the DASH and Wingate.
Conclusions
Eight different patient-reported upper extremity outcome measures have been reported in the peer-review literature for women with breast cancer, some (n=3) were specifically developed for breast cancer survivors and others that were not (n=5). Based on the current evidence we recommend administering the DASH to assess patient-reported upper extremity function in breast cancer survivors because the DASH had most consistently large effects sizes for construct validity and responsiveness. Future large studies are needed for more definitive recommendations.
doi:10.1016/j.apmr.2013.07.022
PMCID: PMC4162515  PMID: 23932969
Breast neoplasms; Upper extremity; Outcome assessment; Rehabilitation
2.  Risk Factors Associated With Shoulder Pain and Disability Across the Lifespan of Competitive Swimmers 
Journal of Athletic Training  2012;47(2):149-158.
Context:
The prevalence of shoulder pain among competitive swimmers is high, but no guidelines exist to reduce shoulder injuries. Elucidating differences between swimmers with and without shoulder pain can serve as a basis for the development of a program to prevent shoulder injury that might lead to pain and dysfunction.
Objective:
To determine whether physical characteristics, exposure, or training variables differ between swimmers with and without shoulder pain or disability.
Design:
Cross-sectional study.
Setting:
Multisite swimming centers.
Patients or Other Participants:
A total of 236 competitive female swimmers aged 8 to 77 years.
Data Collection and Analysis:
Participants completed the Penn Shoulder Score and underwent testing of core endurance, range of motion, muscle force production, and pectoralis minor muscle length and the Scapular Dyskinesis Test. Swimmers were grouped by age for analysis: ages 8 to 11 years (n = 42), 12 to 14 years (n = 43), 15 to 19 years (high school, n = 84), and 23 to 77 years (masters, n = 67). Comparisons were made between groups with and without pain and disability using independent t tests for continuous data and χ2 analyses and Fisher exact tests for categorical data.
Results:
Nine (21.4%) swimmers aged 8 to 11 years, 8 (18.6%) swimmers aged 12 to 14 years, 19 (22.6%) high school swimmers, and 13 (19.4%) masters swimmers had shoulder pain and disability. Differences that were found in 2 or more age groups between athletes with and without shoulder pain and disability included greater swimming exposure, a higher incidence of previous traumatic injury and patient-rated shoulder instability, and reduced participation in another sport in the symptomatic groups (P < .05). Reduced shoulder flexion motion, weakness of the middle trapezius and internal rotation, shorter pectoralis minor and latissimus, participation in water polo, and decreased core endurance were found in symptomatic females in single varying age groups (P < .05).
Conclusions:
Female competitive swimmers have shoulder pain and disability throughout their lives. Given that exposure and physical examination findings varied between athletes with and without substantial pain and disability, a program to prevent shoulder injury that might lead to pain and dysfunction appears warranted and might include exposure reduction, cross-training, pectoral and posterior shoulder stretching, strengthening, and core endurance training.
PMCID: PMC3418126  PMID: 22488280
swimming; exposure variables; injury prevention
3.  Incidence of Injuries in High School Softball and Baseball Players 
Journal of Athletic Training  2011;46(6):648-654.
Context:
Participation in high school sports has grown 16.1% over the last decade, but few studies have compared the overall injury risks in girls' softball and boys' baseball.
Objective:
To examine the incidence of injury in high school softball and baseball players.
Design:
Cohort study.
Setting:
Greenville, South Carolina, high schools.
Patients or Other Participants:
Softball and baseball players (n = 247) from 11 high schools.
Main Outcome Measure(s):
Injury rates, locations, types; initial or subsequent injury; practice or game setting; positions played; seasonal trends.
Results:
The overall incidence injury rate was 4.5/1000 athlete-exposures (AEs), with more injuries overall in softball players (5.6/1000 AEs) than in baseball players (4.0/1000 AEs). Baseball players had a higher initial injury rate (75.9/1000 AEs) than softball players (66.4/1000 AEs): rate ratio (RR) = 0.88, 95% confidence interval (CI) = 0.4, 1.7. The initial injury rate was higher than the subsequent injury rate for the overall sample (P < .0001) and for softball (P < .0001) and baseball (P < .001) players. For both sports, the injury rate during games (4.6/1000 AEs) was similar to that during practices (4.1/1000 AEs), RR = 1.22, 95% CI = 0.7, 2.2. Softball players were more likely to be injured in a game than were baseball players (RR = 1.92, 95% CI = 0.8, 4.3). Most injuries (77%) were mild (3.5/1000 AEs). The upper extremity accounted for the highest proportion of injuries (63.3%). The incidence of injury for pitchers was 37.3% and for position players was 15.3%. The rate of injury was highest during the first month of the season (7.96/1000 AEs).
Conclusions:
The incidence of injury was low for both softball and baseball. Most injuries were minor and affected the upper extremity. The injury rates were highest in the first month of the season, so prevention strategies should be focused on minimizing injuries and monitoring players early in the season.
PMCID: PMC3418943  PMID: 22488191
injury rates; injury epidemiology; athletic injuries
4.  SHOULDER RANGE OF MOTION, PITCH COUNT, AND INJURIES AMONG INTERSCHOLASTIC FEMALE SOFTBALL PITCHERS: A DESCRIPTIVE STUDY 
Background/Purpose:
Injury rates for softball players are similar to baseball players yet information regarding risk factors, pitching, and physical characteristics for high school windmill softball pitchers is limited. This information is needed to guide prevention, training, and rehabilitation efforts. The purpose of this study was to report descriptive data regarding the physical characteristics and pitching volume experienced by high school softball pitchers during one academic season. A secondary aim was to track and describe upper extremity injuries suffered by high school softball pitchers throughout the course of the 2009 season.
Methods:
Twelve uninjured female softball pitchers (13‐18y) from 5 Greenville, South Carolina high schools participated. Prior to the 2009 season, the pitchers' shoulder internal, external, total arc of rotation and horizontal adduction PROM was measured. During the 10‐week season, aggregate pitch counts (pitch volume) and occurrence of upper extremity injury were tracked for each pitcher.
Results:
Mean preseason internal, external, and total arc of rotation PROM was observed to be similar between the pitchers' dominant and non‐dominant shoulders. The PROM measures of horizontal abduction (HA) appear to demonstrate a side‐to‐side difference with less HA on the dominant arm of the pitchers who were examined. Subjects threw in an average of 10.1 games (±4.9) during the season. Six pitchers threw in 60% or more of the team's games and 3 of 12 pitchers pitched less than 25% of games. Pitchers averaged 61.8 pitches per game (±31.5) and 745.8 (±506.4) per season. Pitch count data did not appear to be different between injured and non‐injured pitchers.
Conclusions:
Knowledge of pitch volume can be used to prepare windmill softball pitchers for the seasonal stresses, guide establishment of goals when recovering from injury, or assist in training for an upcoming season. Further research is needed to examine larger samples of pitchers over multiple seasons and years.
Level of Evidence:
III
PMCID: PMC3474308  PMID: 23091788
Pitch count; shoulder; softball
5.  Diagnostic Accuracy of History and Physical Examination of Superior Labrum Anterior-Posterior Lesions 
Journal of Athletic Training  2011;46(4):343-348.
Context:
Type I superior labrum anterior-posterior (SLAP) lesions involve degenerative fraying and probably are not the cause of shoulder pain. Type II to IV SLAP lesions are tears of the labrum.
Objective:
To determine the diagnostic accuracy of patient history and the active compression, anterior slide, and crank tests for type I and type II to IV SLAP lesions.
Design:
Cohort study.
Setting:
Clinic.
Patients or Other Participants:
Fifty-five patients (47 men, 8 women; age = 40.6 ± 15.1 years) presenting with shoulder pain.
Intervention(s):
For each patient, an orthopaedic surgeon conducted a clinical examination of history of trauma; sudden onset of symptoms; history of popping, clicking, or catching; age; and active compression, crank, and anterior slide tests. The reference standard was the intraoperative diagnosis. The operating surgeon was blinded to the results of the clinical examination.
Main Outcome Measure(s):
Diagnostic utility was calculated using the receiver operating characteristic curve and area under the curve (AUC), sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood ratio (−LR). Forward stepwise binary regression was used to determine a combination of tests for diagnosis.
Results:
No history item or physical examination test had diagnostic accuracy for type I SLAP lesions (n = 13). The anterior slide test had utility (AUC = 0.70, +LR = 2.25, −LR = 0.44) to confirm and exclude type II to IV SLAP lesions (n = 10). The combination of a history of popping, clicking, or catching and the anterior slide test demonstrated diagnostic utility for confirming type II to IV SLAP lesions (+LR = 6.00).
Conclusions:
The anterior slide test had limited diagnostic utility for confirming and excluding type II to IV SLAP lesions; diagnostic values indicated only small shifts in probability. However, the combination of the anterior slide test with a history of popping, clicking, or catching had moderate diagnostic utility for confirming type II to IV SLAP lesions. No single item or combination of history items and physical examination tests had diagnostic utility for type I SLAP lesions.
PMCID: PMC3419145  PMID: 21944065
labral tears; diagnostic tests; sensitivity; specificity; likelihood ratio
6.  Using Disablement Models and Clinical Outcomes Assessment to Enable Evidence-Based Athletic Training Practice, Part II: Clinical Outcomes Assessment 
Journal of Athletic Training  2008;43(4):437-445.
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.
PMCID: PMC2474824  PMID: 18668177
quality of life; scales; patient self-report; evidence-based practice
7.  Using Disablement Models and Clinical Outcomes Assessment to Enable Evidence-Based Athletic Training Practice, Part I: Disablement Models 
Journal of Athletic Training  2008;43(4):428-436.
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.
PMCID: PMC2474823  PMID: 18668176
patient-centered care; International Classification of Functioning; health-related quality of life; evidence-based practice; National Center for Medical Rehabilitation Research; Nagi model

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