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

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. 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. 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. Physical and Sport-related
psychosocial
injury
benefits

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. ICF Framework
Snyder, JAT, 2008

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. Health-Related Quality of Life
Physical
Social
Spiritual
Economic
Physiologic
Psychological

9. Whole Person Healthcare
Patient is
central
Health and
illness
involve the
whole person
Narrative
health
history
Whole
Person
Healthcare
Integrated
healthcare
team

10. ICF Framework
Snyder, JAT, 2008

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)

13. • 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

14. 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

15. 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?

16. 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)

17. 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

18. 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

19. 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)

20. 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

21. 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

22. 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)

23. 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

24. 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)

25. 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

26. 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)

27. 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?

28. 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

29. 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.”

30. 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.”

31. 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.”

32. 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)

33. 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)

34. 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)

35. Accommodation Type
Parsons, J Athl Train 2012

36. 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

37. w/ Absence…
Parsons, J Athl Train 2012

38. 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

39. 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

40. 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

41. Stovitz, BJSM, 2010

42. 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

43. 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

44. www.atsuconcussion.com
tmcleod@atsu.edu
480-219-6035
www.atpbrn.org