Journal of Athletic Training 2019;54(4):449–458

doi: 10.4085/1062-6050-108-17
Ó by the National Athletic Trainers’ Association, Inc Patient-Reported Outcomes
www.natajournals.org

Use of Patient-Reported Outcome Measures in Athletic

Training: Common Measures, Selection
Considerations, and Practical Barriers
Kenneth C. Lam, ScD, ATC*; Katie M. Harrington, MS, ATC*;
Kenneth L. Cameron, PhD, MPH, ATC, FNATA†;
Alison R. Snyder Valier, PhD, ATC, FNATA*‡
*Athletic Training Programs, Department of Interdisciplinary Health Sciences, A.T. Still University, Mesa, AZ; †Keller
Army Hospital, West Point, NY; ‡School of Osteopathic Medicine in Arizona, A.T. Still University, Mesa

Context: Current evidence suggests that a low percentage frequently endorsed by the AT-USE group were the Numeric
of athletic trainers (ATs) routinely use patient-reported outcome Pain Rating Scale (n ¼ 128, 34.6%); Lower Extremity Functional
measures (PROMs). An understanding of the perceptions of Scale (n ¼ 108, 29.2%); Disability of the Arm, Shoulder and
ATs who use (AT-USE) and who do not use (AT-NON) PROMs Hand (n ¼ 96, 25.9%); Owestry Disability Index (n ¼ 80, 21.6%);
as well as any differences due to demographic characteristics and Foot and Ankle Ability Measure (n ¼ 78, 21.1%). The most
(eg, use for patient care or research, job setting, highest important criteria reported by AT-USE for selecting PROMs
education level) may help facilitate the use of PROMs in athletic were that the measure was valid and reliable, easy for patients
training.
to understand, and easy for clinicians to understand and
Objective: To describe commonly used PROMs by AT-
USE, the criteria by which AT-USE select PROMs, and reasons interpret. Common reasons for non-use were that PROMs were
for non-use by AT-NON. too time consuming for the clinician, too time consuming for the
Design: Cross-sectional study. patient, and more effort than they were worth.
Setting: Online survey. Conclusions: The Numeric Pain Rating Scale; Lower
Patients or Other Participants: A convenience sample of Extremity Functional Scale; Disability of the Arm, Shoulder
1784 ATs (response rate ¼ 10.7% [1784/17972]; completion rate and Hand; Owestry Disability Index; and Foot and Ankle Ability
¼ 92.2% [1784/1935]) who worked in a variety of settings. Measure were the PROMs most commonly endorsed by AT-
Main Outcome Measure(s): Participants completed an USE and should be considered for athletic training use. To
anonymous electronic online survey. Descriptive statistics were further facilitate the use of PROMs in athletic training, future
used to describe commonly used PROMs, PROM selection authors should identify strategies to address organizational and
criteria, and reasons for PROM non-use. time-constraint obstacles. Interpretation of our study findings
Results: Participants were classified as AT-USE (n ¼ 370, may require caution due to a relatively low response rate and
20.7%) or AT-NON (n ¼ 1414, 79.3%). For the AT-USE group, because ‘‘routine use’’ was not operationalized.
the most common type of PROMs used were specific (eg,
region, joint; n ¼ 328, 88.6%), followed by single-item (n ¼ 258, Key Words: clinical outcomes assessment, health-related
69.7%) and generic (n ¼ 232, 62.7%). Overall, the PROMs most quality of life, disablement, whole-person health care

Key Points
 Athletic trainers who routinely used patient-reported outcome measures reported administering region-specific
measures most often, followed by single-item and generic measures.
 The ease of interpretation for the patient, demonstrated reliability and validity, appropriateness, and completion time
were important factors considered by athletic trainers when evaluating and selecting patient-reported outcome
measures.
 The use of patient-reported outcome measures in athletic training remained relatively low, with level of education,
work setting, and organizational infrastructure influencing their use.

W
ithin the global health care system over the past and care experiences and to establish patient-oriented
decade, efforts have been directed at assessing evidence to better inform patient care decisions.6 For
patient outcomes as part of routine patient care example, through the routine and comprehensive assess-
and clinical research.1–5 Organizations such as the Agency ment of clinical outcomes, including patient-reported
for Healthcare Research and Quality and the Patient- outcomes, clinicians are able to identify effective treat-
Centered Outcomes Research Institute have highlighted the ments, treatment patterns, and areas for improvement.1,4,5,7
need to understand the patient’s perspective on wellness Furthermore, since patient-reported outcomes are typically

Journal of Athletic Training 449

assessed from the patient’s perspective, these outcomes are ‘‘Athletic Training Education Competencies’’11 and ‘‘Role
essential to delivering patient-centered, whole-person Delineation/Practice Analysis’’12 that went into effect for
health care; establishing patient-oriented evidence that entry-level and continuing education efforts in 2011 and
matters; and identifying the effectiveness of treatment 2012, respectively.
interventions.1,4,5,7
Patient-reported outcomes are useful for measuring what METHODS
is important to patients and for evaluating patient
outcomes.7,8 The importance of assessing patient-reported Participants
outcomes in athletic training has been highlighted in the Participants were recruited from a convenience sample of
literature8–10 and by the profession.11,12 For example, the certified ATs who worked in the high school, college/
current editions of the ‘‘Athletic Training Education university, clinic/hospital, industrial, or military/govern-
Competencies’’11 and the ‘‘Role Delineation/Practice Anal- ment setting. They were included if they were certified ATs
ysis’’12 emphasize the need to include patient-reported and members of the National Athletic Trainers’ Association
outcome measures (PROMs) as part of the entry-level (NATA) and were identified in the 2014 end-of-year NATA
competencies (effective in 2011) and continuing education membership e-mail list. Participants were grouped accord-
efforts (effective in 2012), respectively. These PROMs are ing to whether they did or did not use PROMs in clinical
self-report surveys or questionnaires designed to capture practice or research. The study was exempted from
patients’ perspectives about their health status.8,10 A variety continued review by the local institutional review board
of PROMs are available for patient care and clinical because the study data were collected using an anonymous
research. The 3 primary classifications of PROMs are Web-based survey.
generic, specific, and single-item measures. Generic
measures are designed to be applicable to a range of health Procedures
domains and to capture various dimensions of disablement
and health-related quality of life.13 Specific measures are An invitation to take part in the study was sent via e-mail
designed with a particular injury, illness, or body region in to 17 972 ATs in the fall of 2015, and reminder e-mails
mind.13 Thus different types of measures are available, about survey completion were sent 2 and 4 weeks later. The
including measures specific to a body region, joint, disease, survey was closed approximately 5 weeks after the initial
or condition. Single-item measures ask 1 question about a invitation was sent, providing participants with 35 days to
patient’s health status and offer a quick and easy way to complete the survey. Recruits were split into 2 groups
obtain information from the patient.14 However, single-item based on their responses to the following questions: ‘‘Do
measures are limited in the depth of the information you routinely use PRO instruments for clinical practice?’’
provided about the patient’s health status.13 and ‘‘Do you routinely use PRO instruments for clinical
Although current efforts in entry-level11 and continuing12 research?’’ Those who replied yes to either or both
education include patient outcomes assessments and the use questions were grouped as participants who used PROMs
of PROMs, research has suggested that a low percentage of (AT-USE), and those who replied no to both questions were
athletic trainers (ATs) routinely use PROMs. Specifically, grouped as participants who did not use PROMs (AT-
Valier et al15 surveyed a small random sample of practicing NON). Survey completion time was estimated to be
ATs and found that only 26% routinely used PROMs as between 10 and 15 minutes.
part of their usual patient care. In addition to lack of time,
common reasons for non-use included the lack of education Instrumentation
and insufficient understanding of PROMs to successfully Survey Development. We created a survey for the study
implement these tools in routine care.15 For instance, the that consisted of demographic questions, AT-USE ques-
intricate process of selecting the most appropriate PROMs tions, and AT-NON questions. The survey was developed
for athletic health care can hinder their use in athletic in 3 phases: (1) item (question) generation, (2) survey
training, particularly because the majority of available validation, and (3) mechanical review. A panel of 3 experts
PROMs were developed for more general as opposed to was consulted for the item-generation phase of the survey.
athletic populations.9,14,15 To our knowledge, no direct Each expert was a certified AT with an established line of
efforts have been made to identify the PROMs that are most research focused on assessing patient outcomes in physi-
commonly used by ATs who administer them. A better cally active individuals and had previously given profes-
understanding of the PROMs used most often by ATs who sional presentations on the use of PROMs to an athletic
have successfully implemented these tools in routine training audience. For item generation, the experts were
practice may help address the lack of education and the asked to independently generate a list of PROMs relevant to
barriers related to PROM non-use, guide the PROM athletic training, criteria used to select PROMs, and
selection process, and facilitate the use of PROMs by common barriers related to the use of PROMs. Then, they
ATs. Therefore, the primary aims of our study were to discussed the compiled items and reached a consensus on
describe the PROMs commonly used by the ATs who the content to be included in the survey. Because the survey
administered them and the criteria for selecting them. was developed based on the experts’ knowledge of the
Secondarily, we aimed to describe the reasons for non-use current literature, the final list of items was similar to the
by ATs who did not use PROMs. This secondary aim lists previously used by Valier et al15 and Jette et al.16 After
allowed us to expand on previous findings15 by surveying item generation, survey validation was conducted. To
all ATs, regardless of job setting (eg, military/government, evaluate face validity, we asked a small group of clinical
researchers), and provide the first insight into reasons for ATs to review all survey questions for content, clarity, and
non-use after the release of the current editions of the relevance. Wording and formatting changes were made

450 Volume 54  Number 4  April 2019

based on their feedback. After survey validation, the final non-use of PROMs by the AT-NON group were recorded as
set of questions was used to create a Web-based survey ordinal data. Thus, these responses were summarized using
(Qualtrics, LLC, Provo, UT). In the final phase of survey medians and interquartile ranges.19,20 Within each group,
development, a second group of clinical ATs performed a we used v2 (Fisher exact) tests to compare ATs who
mechanical review by completing the Web-based version of classified their current positions as primarily patient care
the survey to ensure that all embedded logic was with those who classified their current positions as
functioning correctly. primarily research to identify any group differences for
Participant Demographic Questions. Demographic (1) PROM selection criteria in the AT-USE group and (2)
questions consisted of sex, years certified as an AT, reasons for non-use of PROMs in the AT-NON group. We
professional (entry-level) athletic training degree, highest used SPSS (version 23.0; IBM Corp, Armonk, NY) for data
earned degree, additional certification(s), current job analysis.
setting, classification of current job setting, and partici-
pant’s NATA district. At the end of this section, RESULTS
participants were asked if they used PROMs for clinical
practice or research. Participant Demographics
The AT-USE Questions. The AT-USE question set Of the 1935 individuals who accessed the survey
consisted of 2 sections. The first section asked about the (response rate ¼ 10.7%), 1732 completed the survey
types of PROMs used by the AT (generic, specific, or (completion rate ¼ 89.5%) and were classified as either
single-item measures). Participants endorsed the PROMs AT-USE (n ¼ 370, 21.7%) or AT-NON (n ¼ 1362, 78.3%).
they used from a drop-down list of PROMs compiled in the Demographics for each group are summarized in Table 1.
survey and were able to write in any other PROMs that In the AT-USE group, 67.6% (n ¼ 250), 9.5% (n ¼ 35),
were not included in the list. The second section asked 9.7% (n ¼ 36), and 13.2% (n ¼ 49) classified their current
participants to rate the importance of specific selection position as patient care only, research only, patient care and
criteria when evaluating a PROM for use, including research, or other, respectively. In the AT-NON group,
completion time, ease of interpretation, and established 86.2% (n ¼ 1179), 1.5% (n ¼ 20), 1.6% (n ¼ 22), and 10.7%
measurement properties. Each selection criterion was rated (n ¼ 146) classified their current position as patient care
on a 5-point, Likert-like response scale (1 ¼ not important, only, research only, patient care and research, or other,
5 ¼ very important). respectively.
The AT-NON Questions. The AT-NON question set The v2 test results were significant for professional
asked participants to rate their reasons for not using athletic training degree (v2 ¼ 4.10, P ¼ .04), highest degree
PROMs, including time for patients to complete, time for earned (v2 ¼ 108.3, P , .001), and current job setting (v2 ¼
ATs to score, and effort-to-benefit perspective. Each 101.5, P , .001), with those holding doctoral degrees
component was rated on a 5-point Likert response scale (clinical doctorate, doctorate, postdoctorate), those holding
(1 ¼ strongly disagree, 5 ¼ strongly agree). professional athletic training degrees at the bachelor’s
level, and those working in the clinic, hospital, and
Data Analysis military/government settings reporting the use of PROMs
more frequently than other groups within the same variable,
Based on a population size of 17 972 ATs, an estimated respectively. The v2 findings were not significant for sex
1672 responses (9.3% response rate) were needed to obtain (v2 ¼ 1.29, P ¼ .26) or years certified (v2 ¼ 3.50, P ¼ .48).
results that were accurate at a 99% confidence level with
63% margin of error.17 We used frequency counts and
percentages to summarize patient demographics based on The AT-USE Results
AT-USE and AT-NON groups. For the AT-USE group, 51.6% (n ¼ 191) reported using
We also compared the AT-USE and AT-NON groups to PROMs for clinical practice only, 24.6% (n ¼ 91) for
determine if they differed in participant demographics. We research purposes only, and 23.8% (n ¼ 88) for both clinical
used v2 (Fisher exact) tests to compare the AT-USE and practice and research purposes. Athletic trainers reported
AT-NON groups by age, sex (male, female), years certified that they most frequently used specific PROMs (n ¼ 328,
(,3 years, 3–5 years, 6–10 years, 11–20 years, .20 years), 88.6%) followed by single-item (n ¼ 258, 69.7%) and
professional athletic training degree (bachelor’s, master’s), generic (n ¼ 232, 62.7%) PROMs. Summaries of responses
highest degree earned (bachelor’s, entry-level master’s, for specific, single-item, and generic PROMs are reported
postprofessional master’s, master’s in a related field, in Tables 2, 3, and 4, respectively. Of the ATs who used
clinical doctorate, doctoral, postdoctoral), and current job specific PROMs (n ¼ 328), the knee (n ¼ 236, 72.0%), foot
setting (high school, college/university, 2-year institution, and ankle (n ¼ 212, 64.6%), and shoulder and elbow (n ¼
clinic/outreach, clinic, hospital, industrial/occupational, 204, 62.2%) were the most commonly reported body
military/government). For significant v2 test results, we regions (Table 2). The least common body regions for
conducted pairwise comparisons using z-scores with which ATs reported using PROMs were the head (n ¼ 118,
Bonferroni adjustments18 to identify differences between 36.0%), neck (n ¼ 100, 30.5%), and wrist and hand (n ¼ 99,
groups. Bootstrapping was also used to provide a more 30.2%). The most commonly endorsed specific PROMs by
conservative estimate of the population parameters. ATs who used specific PROMs (n ¼ 328) were the Lower
We calculated frequency counts and percentages to Extremity Functional Scale (LEFS; n ¼ 108, 32.9%);
summarize commonly used PROMs as reported by the Disabilities of the Arm, Shoulder and Hand (DASH; n ¼ 96,
AT-USE group. Survey responses related to the selection 29.2%); Oswestry or Modified Oswestry Disability Index (n
criteria of PROMs by the AT-USE group and reasons for ¼ 80, 24.4%); and Foot and Ankle Ability Measure (n ¼ 78,

Journal of Athletic Training 451

Table 1. Participant Demographics
Group, No. (%)
AT-USE
Both Clinical and
Demographic Characteristic Clinical Use Only Research Use Only Research Use AT-NON

Sex
Male 86 (44.8) 34 (37.8) 40 (45.5) 630 (46.1)
Female 105 (55.2) 57 (62.2) 48 (54.5) 732 (53.5)
Years certified
,3 31 (16.2) 14 (15.4) 6 (6.8) 170 (12.5)
3–5 36 (18.8) 15 (16.5) 22 (25.0) 301 (22.1)
6–10 42 (22.0) 13 (14.3) 19 (21.6) 287 (21.1)
11–20 39 (20.4) 27 (29.7) 23 (26.1) 347 (25.5)
.20 43 (22.5) 22 (24.2) 18 (20.5) 257 (18.8)
Professional athletic training degree
Bachelor’s 156 (81.7) 82 (90.1) 74 (84.1) 1088 (79.6)
Master’s 35 (18.3) 9 (9.9) 14 (14.9) 274 (20.0)
Highest degree earned
Bachelor’s 53 (27.7) 15 (16.5) 9 (10.2) 323 (23.6)
Entry-level master’s 14 (7.3) 2 (2.2) 2 (2.3) 90 (6.6)
Postprofessional master’s 21 (11.0) 9 (9.9) 12 (13.6) 177 (12.9)
Master’s in related field 87 (45.5) 29 (31.9) 37 (42.0) 698 (51.1)
Clinical doctorate (eg, DAT, DPT, DHSc) 10 (5.2) 2 (2.2) 13 (14.8) 12 (0.9)
Doctoral (eg, PhD, EdD, ScD) 6 (3.1) 29 (31.9) 14 (15.9) 61 (4.5)
Postdoctoral 0 (0.0) 5 (5.5) 1 (1.1) 1 (0.1)
Current job setting
High school 41 (21.5) 11 (12.1) 8 (9.1) 481 (35.3)
College/university 59 (30.9) 62 (68.1) 36 (40.9) 535 (39.3)
Two-year institution (college) 2 (1.0) 0 (0.0) 2 (2.3) 44 (3.2)
Clinic/outreach 31 (16.2) 9 (9.9) 6 (6.8) 158 (11.6)
Clinic 35 (18.3) 2 (2.2) 24 (27.3) 65 (4.8)
Hospital 10 (5.2) 3 (3.3) 7 (8.0) 42 (3.2)
Industrial/occupational 7 (3.7) 1 (1.1) 1 (1.1) 23 (1.7)
Military/government 2 (1.0) 2 (2.2) 3 (3.4) 12 (0.9)
Position classification (select all that apply)
Patient care 174 (91.1) 49 (53.8) 63 (71.6) 1201 (87.9)
Education 52 (27.2) 46 (50.5) 39 (44.3) 417 (30.5)
Administrative 49 (25.7) 27 (29.7) 29 (33.0) 347 (25.4)
Research 10 (5.2) 34 (37.4) 27 (30.7) 42 (3.1)
National Athletic Trainers’ Association district
1 17 (8.9) 5 (5.5) 7 (8.0) 121 (8.9)
2 25 (13.1) 9 (9.9) 8 (9.1) 191 (14.0)
3 22 (11.5) 13 (14.3) 8 (9.1) 162 (11.9)
4 44 (23.0) 26 (28.6) 17 (19.3) 272 (20.0)
5 10 (5.2) 7 (7.7) 9 (10.2) 144 (10.6)
6 6 (3.1) 5 (5.5) 4 (4.5) 82 (6.0)
7 20 (10.5) 6 (6.6) 8 (9.1) 87 (6.4)
8 12 (6.3) 10 (11.0) 9 (10.2) 86 (6.3)
9 28 (14.7) 9 (9.9) 10 (11.4) 151 (11.1)
10 7 (3.7) 1 (1.1) 8 (9.1) 65 (4.8)
Abbreviations: AT-NON, athletic trainers who did not use patient-reported outcome measures; AT-USE, athletic trainers who used patient-
reported outcome measures; DAT, doctor of athletic training; DHSc, doctor of health science; DPT, doctor of physical therapy.

23.8%). Athletic trainers who reported using single-item ment at all, indicating low usage in athletic training practice
PROMs most often cited the Numeric Pain Rating Scale (n (Tables 2 through 4).
¼ 128, 49.6%), the Global Rating of Change Scale (n ¼ 59, In terms of PROM selection (Table 5), the most
22.9%), and the Patient Specific Functional Scale (n ¼ 44, commonly endorsed criteria were being easy for patients
17.1%; Table 3). The most frequently endorsed generic to understand, shown to be valid and reliable, being easy for
PROMs were the Short Form-12 (SF-12) or Short Form-36 clinicians to understand and interpret the meaning of scores
(SF-36; n ¼ 57, 36.5%) and the Disablement in the and changes in scores, and being most appropriate for the
Physically Active (DPA) scale (n ¼ 39, 25.0%; Table 4). types of conditions seen in the AT’s practice setting. The
Many PROMs received few endorsements or no endorse- least often endorsed selection criteria were being useful for

452 Volume 54  Number 4  April 2019

Table 2. Commonly Used Specific Patient-Reported Outcomes Table 2. Continued
Measures by Body Region (n ¼ 328)
Body Part No. (%)
Body Part No. (%)
Michigan Hand Outcomes Questionnaire 2 (2.0)
Patient-Rated Wrist Evaluation Questionnaire 2 (2.0)
Foot and ankle (n ¼ 212)
Brigham and Women’s Carpal Tunnel Questionnaire 0 (0.0)
Foot and Ankle Ability Measure 78 (36.8) Gartland and Werley Score 0 (0.0)
Foot and Ankle Disability Index 64 (30.2)
AAOS Foot and Ankle Core Score 28 (13.2) Neck (n ¼ 100)
Lower Extremity Functional Scale 11 (5.2) Neck Disability Index 52 (52.0)
Sports Ankle Rating Quality of Life Measure 11 (5.2) Copenhagen Neck Functional Disability Scale 3 (3.0)
Foot Function Index 7 (3.3) Northwick Park Therapy Dependency Assessment 0 (0.0)
Foot Health Status Questionnaire 4 (1.9) Head (n ¼ 118)
Knee (n ¼ 236) Headache Impact Test (HIT-6) 31 (26.3)
Lower Extremity Functional Scale 108 (45.8) Profiles of Mood States 13 (11.0)
Knee Osteoarthritis Outcome Score 56 (23.7) Dizziness Handicap Inventory 13 (11.0)
International Knee Documentation Committee 55 (23.3) Multidimensional Fatigue Scale 7 (5.9)
Cincinnati Knee Scale 20 (8.5) Patient-Rated Outcomes Measurement Information
Lysholm Knee Functioning Scoring Scale 19 (8.1) System 7 (5.9)
Tegner Activity Level Rating Scale 18 (7.6) Beck Depression Inventory 6 (5.1)
Western Ontario and McMaster Universities Traumatic Brain Injury Quality of Life 5 (4.2)
Osteoarthritis Index 16 (6.8) Satisfaction with Life Scale 4 (3.4)
Kujala Patellofemoral Score/Anterior Knee Pain Score 15 (6.4) Quality of Life After Brain Injury 3 (2.5)
Western Ontario Meniscal Evaluation Tool 5 (2.1) NeuroQOL (Quality of Life in Neurological Disorders) 2 (1.7)
Oxford Knee Score 3 (1.3)
Hip (n ¼ 128)
Lower Extremity Functional Scale 54 (42.2)
a variety of purposes, such as research, quality assurance,
Hip Disability and Osteoarthritis Outcome Score 17 (13.3)
and patient evaluation; suitability for electronic analysis;
Hip Outcome Score 16 (12.5) and seeming to be the most frequent ones used in athletic
American Academy of Orthopaedic Surgeons Hip and training practice. When we compared responses based on
Knee Score 9 (7.0) classification of current job setting, ATs who were
Harris Hip Score 9 (7.0) primarily responsible for patient care rated the following
Western Ontario and McMaster Universities criteria to be of less importance than those who were
Osteoarthritis Index 4 (3.1) primarily responsible for research: shown to be valid and
Nonarthritic Hip Score 3 (2.3) reliable (P ¼ .03), useful for a variety of purposes (P ¼ .02),
Back (n ¼ 153) and can be analyzed electronically (P ¼ .03). No group
Oswestry or Modified Oswestry Disability Index 80 (52.3) differences were reported for the remaining selection
Low Back Outcome Score 17 (11.1) criteria (P values ¼ .07–.99).
Roland Morris Disability Questionnaire 14 (9.2)
Waddell Disability Index 6 (3.9)
North American Spine Society Lumbar Spine
The AT-NON Results
Assessment Instrument 3 (2.0) Of the ATs who did not use PROMs, the most commonly
Quebec Back Pain and Disability Scale 3 (2.0) endorsed reasons for non-use (Table 6) were that they
Shoulder and elbow (n ¼ 204) require a support structure that I do not have (eg,
Disabilities of the Arm Shoulder and Hand (DASH) 96 (47.1) technology, staff), take too long for clinicians to analyze/
QuickDASH 46 (22.5) calculate/score, and take too much time for patients to
Upper Extremity Functional Scale 21 (10.3) complete. The least frequently endorsed reasons for non-
Functional Arm Scale for Throwers 18 (8.8) use were that they require too high a reading level for many
Shoulder Pain and Disability Index 17 (8.3) patients; are not sensitive to the cultural/ethnic concerns of
Kerlan-Jobe Orthopaedic Clinic Questionnaire 15 (7.4)
many of the ATs’ patients; and are in English, a language
American Shoulder and Elbow Surgeons Self-Report
Form 8 (3.9)
Pennsylvania Shoulder Score 5 (2.5) Table 3. Commonly Used Single-Item Patient-Reported Outcome
Shoulder Rating Questionnaire 4 (2.0) Measures (n ¼ 258)
Shoulder Disability Questionnaire 2 (1.0) Instrument No. (%)
Simple Shoulder Test 2 (1.0)
Western Ontario Shoulder Instability Index 2 (1.0) Numeric Pain Rating Scale 128 (49.6)
Flexilevel Scale for Shoulder Function 1 (0.5) Global Rating of Change Scale 59 (22.9)
Oxford Shoulder Score 1 (0.5) Patient-Specific Functional Scalea 44 (17.1)
Upper Limb Functional Limitation Scale 1 (0.5) Global Rating of Function 24 (9.3)
Constant Murley Shoulder Score 0 (0.0) Patient Rating of Satisfaction With Care 16 (6.2)
University of California, Los Angeles, Shoulder Rating Global Rating of Disability 11 (4.3)
Score 0 (0.0) Single Assessment Numeric Evaluation 10 (3.9)
Patient Rating of Satisfaction With Injured Body Part 7 (2.7)
Wrist and hand (n ¼ 99) Patient Acceptable Symptom State 1 (0.4)
DASH 40 (40.4) a
The Patient-Specific Functional Scale is formally a 3- to 5-item
QuickDASH 19 (19.2)
measure. However, because it is neither a specific nor generic
Upper Extremity Functional Scale 10 (10.1)
measure, we classified it as a single-item measure.

Journal of Athletic Training 453

Table 4. Commonly Used Generic Patient-Reported Outcome used PROMs. Although these tools provide a glimpse of the
Measures (n ¼ 156) patient’s perspective, which should enhance patient care,
Instrument No. (%) their emphasis on function limits the ability to obtain a
Short Form-12 or Short Form-36 57 (36.5) whole-person perspective on how the health condition
Disablement in the Physically Active 39 (25.0) affects the patient. Comprehensive, whole-person care
Short Musculoskeletal Functional Assessment 21 (13.5) requires attention to all levels of disablement, including
Pediatric Quality of Life Inventory 19 (12.2) body structure and function, activity, and participation.7,10
Musculoskeletal Functional Assessment 17 (10.9) Because specific PROMs tend to emphasize activity level, a
Pediatric Outcomes Data Collection Instrument 2 (1.3) generic measure should be included to complement the
Sickness Impact Profile 1 (0.6) information identified with specific measures.8,10,30
In our study, almost 70% of ATs who used PROMs also
in which many of my patients are not fluent. When reported using single-item measures. Single-item measures
comparing responses based on classification of current job ask only 1 question about the patient’s health or perception
setting, ATs who were primarily responsible for patient of his or her health status, making them quick and easy
care rated the following criteria to be of less importance instruments to administer, score, and complete.15,16 When
than those who were primarily responsible for research: used in combination, multiple single-item measures can
they require too high a reading level for many patients (P ¼ potentially capture several levels of disablement, yet they
.03) and are in English, a language in which many of my do so in less depth than multi-item measures. For example,
patients are not fluent (P ¼ .03). No group differences were the Numeric Pain Rating Scale, Global Rating of Function,
reported for the remaining reasons for non-use (P values ¼ and Global Rating of Disability capture levels of body
.06.99). structure and function, activity, and participation. Based on
our findings, it appears that, although ATs used the
Numeric Pain Rating Scale, they rarely used the Global
DISCUSSION Rating of Function or the Global Rating of Disability.
The primary purpose of our study was to identify PROMs Future efforts to better educate clinicians on the use of
commonly used by ATs who administer PROMs in order to single-item outcome measures and their benefits for quick
facilitate the implementation of PROMs in athletic health and easy outcomes assessment are needed, particularly
care for patient care and research. To our knowledge, we when time is a major barrier to their use.15,16
are the first to explicitly identify the most commonly used Our results also suggest that more than 60% of ATs who
PROMs among ATs. Our results suggest that ATs most used PROMs administered generic measures. In contrast to
often reported using region-specific PROMs, followed by specific measures, generic measures typically target a wide
single-item and generic PROMs. The ATs’ preference for range of health domains, often assessing health-related
region-specific measures was not surprising. Because quality of life and how the condition affects the patient
specific measures were designed for a particular injury, from a whole-person perspective.10,31 Thus, generic mea-
disease, or illness, they were structured to capture small and sures can often provide information beyond a person’s self-
important changes over time more easily than generic report of function. In addition, because generic measures
measures.10,21 Another reason that region-specific PROMs are not designed with a particular injury or illness in mind,
may be used more often than other types of PROMs is that they can be used among different patient populations and
they typically focus on function, which is a major concern patients with different injuries.8,10,30 This, in turn, allows
of athletic patients. A review of the current literature clinicians and researchers to make broad comparisons
suggested that the DASH22–24 and LEFS25–29 were com- across groups with various demographic characteristics.10,32
monly used in the sports medicine community to assess Though generic measures offer several benefits to patient
self-reports of function. In our study, the DASH and LEFS care, they may also have limitations. For example, generic
were also frequently endorsed specific PROMs by ATs who measures are not developed with a patient population in

Table 5. Athletic Trainers’ Ratings of Importance of Specific Selection Criteria When Choosing Patient-Reported Outcome Measures
Response, No. (%)
Median
Not Slightly Moderately Very (Interquartile
Criterion Important Important Important Important Important Range)
Easy for patients to understand 1 (0.3) 1 (0.3) 9 (3.1) 78 (27.0) 200 (69.3) 5 (4,5)
Shown to be valid and reliable 0 (0.0) 1 (0.3) 16 (5.5) 96 (33.2) 176 (60.9) 5 (4,5)
Easy for clinicians to understand/interpret
meaning of scores and change in scores 1 (0.3) 3 (1.0) 34 (11.8) 109 (37.7) 142 (49.2) 4 (3,5)
Most appropriate for the types of conditions
seen in my practice setting 3 (1.0) 5 (1.7) 28 (9.7) 121 (41.9) 132 (45.7) 4 (3,5)
Can be completed quickly 2 (0.7) 4 (1.4) 43 (14.9) 115 (39.9) 124 (43.1) 4 (3,5)
Useful for a variety of purposes (eg,
research, quality assurance, patient
evaluation) 12 (4.2) 30 (10.4) 46 (16.0) 128 (44.4) 72 (25.0) 4 (2,5)
Can be analyzed electronically (eg,
scanner, computer) 35 (12.1) 36 (12.5) 59 (20.4) 88 (30.4) 71 (24.6) 4 (3,5)
Seem to be the most common ones used
in athletic training practice 43 (14.9) 54 (18.8) 84 (29.2) 75 (26.0) 32 (11.1) 3 (1,5)

454 Volume 54  Number 4  April 2019

Table 6. Athletic Trainers’ Reasons for Non-Use of Patient-Reported Outcome Measures
Response, No. (%)
Median
Strongly Strongly (Interquartile
Reason Disagree Disagree Neutral Agree Agree Range)
Require a support structure that I do not have (eg,
technology, staff) 46 (4.0) 163 (14.3) 402 (35.3) 373 (32.7) 158 (13.9) 3 (2,4)
Take too much of clinician’s time to analyze/calculate/
score 33 (2.9) 155 (13.6) 449 (39.3) 381 (33.3) 125 (10.9) 3 (2,4)
Take too much time for patients to complete 45 (3.9) 163 (14.3) 451 (39.5) 369 (32.3) 114 (10.0) 3 (2,4)
Often not completed at discharge so are not useful
for determining patient response to treatment 41 (3.6) 165 (14.4) 647 (56.6) 245 (21.5) 45 (3.9) 3 (2,4)
Require more effort than they are worth 59 (5.2) 236 (20.6) 562 (49.1) 234 (20.4) 54 (4.7) 3 (1,5)
Are difficult to interpret 53 (4.6) 238 (20.8) 573 (50.2) 251 (22.0) 27 (2.4) 3 (2,4)
Do not contain items or questions that are relevant
for the types of patients I see 55 (4.8) 224 (19.6) 597 (52.2) 219 (19.2) 48 (4.2) 3 (3,3)
Require training that I do not have 131 (11.4) 274 (23.9) 502 (43.8) 190 (16.6) 48 (4.3) 3 (2,4)
Are really only used for research purposes 101 (8.9) 303 (26.6) 574 (50.2) 143 (12.5) 20 (1.8) 3 (2,4)
Provide information that is too subjective to be useful 66 (5.8) 325 (28.5) 599 (52.4) 132 (11.5) 21 (1.8) 3 (2,4)
Do not contain information that helps direct the plan
of care 72 (6.3) 363 (31.7) 557 (48.6) 134 (11.7) 19 (1.7) 3 (2,4)
Are difficult for patients to complete independently 103 (9.0) 356 (31.1) 539 (47.0) 144 (12.6) 4 (0.3) 3 (2,4)
Make patients anxious 137 (12.0) 307 (26.8) 571 (49.9) 124 (10.8) 6 (0.5) 3 (2,4)
Cost too much 148 (13.0) 263 (23.2) 607 (53.4) 101 (8.9) 17 (1.5) 3 (2,4)
Are confusing for patients 113 (9.9) 348 (30.4) 625 (54.4) 57 (5.0) 5 (0.3) 3 (2,4)
Are not relevant 148 (12.9) 347 (30.3) 550 (48.0) 69 (6.1) 31 (2.7) 3 (2,4)
Require too high a reading level for many patients 214 (18.7) 397 (34.7) 478 (41.7) 51 (4.5) 5 (0.4) 2 (1,3)
Are not sensitive to the cultural/ethnic concerns of
many of my patients 266 (23.3) 322 (28.1) 511 (44.7) 42 (3.6) 3 (0.3) 2 (1,3)
Are in English, a language in which many of my
patients are not fluent 384 (33.5) 305 (26.6) 415 (36.2) 37 (3.3) 5 (0.4) 2 (1,4)

mind, so they may not be as efficient in or sensitive to literature on instrument selection supports these findings.
capturing small and important changes as specific measures For example, Kyte et al36 recommended that factors to
are. Also, generic measures are designed to be used for a consider when selecting a PROM include its measurement
broad range of patients; therefore, some of the items may be properties (ie, reliability, validity, and responsiveness) and
perceived as lacking relevance to high-functioning patient appropriateness for the patient population. Appropriateness
populations, such as athletes.8,10 Due to these limitations, applies to the wording in the questions and the patient
an often recommended best practice8–10 is to use both burden when completing the instrument.36 The criterion of
generic and specific PROMs to ensure that the clinician time was not surprising because ATs are typically expected
evaluates the patient from a whole-person perspective and to provide fast-paced, high-volume patient care under time
can measure small and important changes over the course limitations. When considering the ATs’ current job
of care. classification, the selection criteria for ATs who used
Given the potential limitations of generic measures in PROMs primarily for patient care did not generally differ
athletic health care, it was surprising that the DPA33 was from those who used PROMs for research purposes.
not more frequently endorsed in our study (n ¼ 39, 25.0%). Interestingly, ATs who were primarily responsible for
The DPA is a generic PROM designed specifically for patient care rated the importance of a PROM being valid
highly functional patients. Lack of endorsement of the DPA and reliable lower than their peers who were primarily
may have been because it is a relatively new instrument and responsible for research. This may suggest that future
potentially less familiar to clinicians than the SF-12 or SF- educational efforts should emphasize the importance of
36. Although the measure is new, recent investigators who using PROMs that are valid and reliable to support global
used the DPA found it to be feasible34 and reliable35 in professional efforts. For example, it would be challenging
high-functioning patients. Furthermore, physical and men- to demonstrate the value of ATs and identify effective
tal composite scores have been established that may help treatments and services provided by ATs without the use of
ATs gain more insight into the patient’s perspective.34 As valid and reliable measures.8–10
ATs continue to integrate PROMs into daily practice and Although gaining an understanding of the PROMs often
clinical research, the DPA may be a useful generic PROM used by ATs is important, it should be noted that the use of
to consider. PROMs in athletic training was relatively minimal.
A second aim of our study was to gain a better Specifically, only 1 in 5 ATs used PROMs on a routine
understanding of how ATs who used PROMs identified basis. This is similar to previous findings in athletic
and selected them for patient care and research. Our training,15 suggesting that the recommendations of the
findings suggest that criteria such as ease of understanding ‘‘Athletic Training Education Competencies’’11 and the
for the patient, demonstrated reliability and validity, ‘‘Role Delineation/Practice Analysis’’12 may have had little
appropriateness, and completion time were important effect in encouraging the use of PROMs in athletic training
factors when evaluating and selecting a PROM. The current practice thus far. Although the percentage was low, it is in

Journal of Athletic Training 455

line with results from other health care professions, such as more formal organizational policies. Future efforts by the
physical therapy, occupational therapy, and speech and athletic training profession should aim to identify strategies
language therapy.37 When considering whether certain that help ATs optimize organizational infrastructure and
demographic factors influenced the use or non-use of support to encourage the use of PROMs in patient care.
PROMs in athletic training, it appears that education and One limitation of our study was the relatively low
work setting may have affected the use of PROMs. Our response rate (10.7%). However, similar response rates
findings suggest that individuals who had doctoral training have been reported in other athletic training studies.45–47 To
were more likely to report using PROMs. This may speak our knowledge, our results reflect the highest response rate
to the notion that additional education may influence of ATs concerning their practice patterns and the use of
whether an AT will use PROMs. This is reasonable PROMs in athletic health care. Also, the publicly available
considering that one of the major reasons for non-use was demographic information of NATA members (eg, sex, job
lack of training as reported by ATs15 and physical setting, highest level of education, district)48,49 was similar
therapists.14 In addition, it appears that the work setting to the percentages observed in our sample, supporting the
can affect the use of PROMs; individuals working in clinic, representativeness of our sample and the generalizability of
hospital, and military/government settings were more likely our findings. Lastly, the final response size of 1784
to use them. exceeded the threshold needed to provide results that were
Beyond potential differences based on demographic accurate at a 99% confidence level and 63% margin of
factors, an understanding of barriers related to the non-use error. Thus, our results likely provide a better estimate of
of PROMs is essential in guiding future efforts for increasing the population value than those of Valier et al,15 who
the use of these instruments. As in most health care settings, reported a 31% response rate, though their study was
the lack of time to complete, score, and interpret PROMs is a powered for a 40% response rate, 95% confidence level,
major barrier.37–40 Technology may help to alleviate these and 64% margin of error. For these reasons, we believe our
time constraints.39 For example, resources such as Web results add meaningful information to the current literature
sites41 and electronic medical records42 can facilitate the and provide beneficial insights into the use and non-use of
completion and scoring of PROMs, thus reducing the time PROMs in athletic training. Another possible limitation is
burden. Also, efforts have been focused on using computer- that although we made efforts to be inclusive and
adaptive testing methods for PROMs,43,44 reducing the comprehensive in our list of PROMs, some available
overall number of items patients complete, and further measures were not included as options in our survey. Even
limiting the time needed to administer the instrument and though respondents were able to cite PROMs not included
calculate and interpret scores. Future educational efforts in our study by typing in entries, some instruments may
should focus on identifying and developing ways to use have been missed. Lastly, we did not operationalize the
technology to encourage more routine use of PROMs. term routinely when asking the participants whether or not
Additionally, researchers in athletic training should consider they routinely used PROMs for clinical practice or clinical
using computer-adaptive testing methods. research, which they may have interpreted differently.
Our findings also suggest that the lack of organizational
Despite these limitations, we believe the findings from our
infrastructure is a major barrier to the routine use of PROMs.
study provide important information on the current use of
Previous investigators in a variety of health care profes-
PROMs among ATs.
sions,39 including rehabilitation health sciences (eg, physical
therapy, occupational therapy, and speech and language
therapy)37 and palliative care,38 have highlighted the CONCLUSIONS
importance of a supportive organizational infrastructure in We aimed to describe PROMs commonly used by ATs
encouraging PROM use. Essential components of organiza- who administered PROMs, the criteria by which ATs selected
tional support for PROM use include policies to guide PROM PROMs, and the reasons for non-use by ATs who did not
use,40 clear guidelines for implementing PROMs,39 manage- administer PROMs. Although the overall use of PROMs in
rial involvement and support (eg, managerial appreciation for athletic training remained low, those who did use PROMs
the extra effort, involvement in the implementation pro- reported administering a variety of different types. Generally,
cess),38,40 adequate resources (eg, training, technical support, specific PROMs, such as the Foot and Ankle Ability
statistical support, data interpretation),37,39 and additional Measure, LEFS, and DASH, were the most commonly
administrative support (eg, a PROM coordinator).38 In our reported PROMs used by ATs, but more than half also
study, we found that ATs practicing in clinics, hospitals, and indicated using single-item and generic measures. When
military/government settings, which likely have more robust selecting a PROM, ATs often consider the time burden for
and defined organizational infrastructures, were more likely the patient and the clinician and the measurement properties
to use PROMs than ATs working in more traditional settings, of the PROM. To encourage greater use of PROMs in the
such as secondary schools, that may have limited resources. athletic training profession, efforts are needed to address
Because most ATs do not work in traditional medical settings common barriers, such as lack of time, and to identify
or under the medical model, professional efforts are needed to effective strategies (eg, use of multiple single-item measures,
identify ways of providing clinicians with more support for leveraging available technology) to help ATs implement
PROM use. For example, professional organizations, such as PROMs more routinely into patient care and research.
the NATA, may consider providing resources such as
training, technical support, statistical support, and data
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Address correspondence to Kenneth C. Lam, ScD, ATC, Department of Interdisciplinary Health Sciences, A.T. Still University, 5850
East Still Circle, Mesa, AZ 85206. Address e-mail to klam@atsu.edu.

458 Volume 54  Number 4  April 2019