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Improving Performance in Practice (IPIP) is a large system intervention designed to align efforts and motivate the creation of a tiered system of improvement at the national, state, practice, and patient levels, assisting primary-care physicians and their practice teams to assess and measurably improve the quality of care for chronic illness and preventive services using a common approach across specialties. The long-term goal of IPIP is to create an ongoing, sustained system across multiple levels of the health care system to accelerate improvement. IPIP core program components include alignment of leadership and leadership accountability, promotion of partnerships to promote health care quality, development of attractive incentives and motivators, regular measurement and transparent sharing of performance data, participation in organized quality improvement efforts using a standardized model, development of enduring collaborative improvement networks, and practice-level support. A prototype of the program was tested in 2 states from March 2006 to February 2008. In 2008, IPIP began to spread to 5 additional states. IPIP uses the leadership of the medical profession to align efforts to achieve large-scale change and to catalyze the development of an infrastructure capable of testing, evaluating, and disseminating effective approaches directly into practice. (Contains 3 figures and 1 table.)

Context: Knee osteoarthritis (OA) frequently develops following knee injury/surgery. It is accepted that knee injury/surgery precipitates OA with previous studies examining this link in terms of years after injury/surgery. However, postinjury OA prevalence has not been examined by decade of life; thereby, limiting our understanding of the age at which patients are diagnosed with posttraumatic knee OA. Objective: Evaluate the association between the knee injury and/or surgical history, present age, and history of receiving a diagnosis of knee OA. Design: Cross-sectional survey. Setting: Online survey. Participants: A total of 3660 adults were recruited through ResearchMatch©. Of these, 1723 (47.1%) were included for analysis due to history of (1) knee surgery (SURG: n = 276; age = 53.8 [15.3] y; and body mass index [BM1]=29.9 [8.0] kg/m²), (2) nonsurgical knee injury (INJ: n = 449; age = 46.0 [15.61 y; and BMI = 27.5 [6.9] kg/m²), or (3) no knee injury (CTRL: n = 998; age = 44.0 [25.2] y; and BMI = 26.9 [6.6] kg/m2). Respondents were subdivided by decade of life (20-29 through 70+). Intervention: An electronic survey regarding knee injury history, treatment, and diagnosis of knee OA. Main Outcome Measures: Binary logistic regression determined the association between knee surgical status and OA by decade of life. Participants with no histories of OA or lower-extremity injury were the referent categories. BMI was a covariate in all analyses. Results: SURG respondents were more likely to report having knee OA than CTRL for all age groups (odds ratios: 11.43-53.03; P< .001). INJ respondents aged 30 years and older were more likely to have OA than CTRL (odds ratios: 2.99-14.22; P< .04). BMI influenced associations for respondents in their 50s (P = .001) and 60s (P < .001) only. Conclusions: INJ increased the odds of reporting a physician diagnosis of knee OA in adults as young as 30 to 39 years. Importantly, SURG yielded 3 to 4 times greater odds of being diagnosed with knee OA compared with INJ in adults as young as 20 to 29 years. Delaying disease onset in these young adults is imperative to optimize the quality of life long term after surgery. [ABSTRACT FROM AUTHOR]

Context: Functional tests are limited primarily by measuring only physical performance. However, athletes often multitask, and deal with complex visual-spatial processing while being engaged in physical activity. Objective: To present the development and reliability of 4 new neurocognitive single-leg hop tests that provide more ecological validity to test sport activity demands than previous functional return to sport testing. Design: Cross-sectional. Setting: Gymnasium. Participants: Twenty-two healthy participants (9 males and 13 females; 20.9 [2.5] y, 171.2 [11.7] cm, 70.3 [11.0] kg) were recruited. Interventions: Maximum distance (physical performance) and reaction time (cognitive performance) were measured for 3 of the neurocognitive hop tests all testing a different aspect of neurocognition (single-leg central-reaction hop—reaction time to 1 central stimulus, single-leg peripheral-reaction crossover hop—reaction time between 2 peripheral stimuli, and single-leg memory triple hop—reaction to memorized stimulus with distractor stimuli). Fastest time (physical performance) and reaction time (cognitive performance) were measured for the fourth neurocognitive hop test (single-leg pursuit 6m hop—requiring visual field tracking [pursuit] and spatial navigation). Main Outcome Measures: Intraclass correlation coefficients were calculated to assess reliability of the 4 new hop tests. Additionally, Bland–Altman plots and 1-sample t tests were conducted for each single-leg neurocognitive hop to evaluate any systematic changes. Results: Intraclass correlation coefficients based on day 1 and day 2 scores ranged from.87 to.98 for both legs for physical and cognitive performance. The Bland–Altman plots and 1-sample t tests (P >.05) indicated that all 4 single-leg neurocognitive hop tests did not change systematically. Conclusions: These data provide evidence that a neurocognitive component can be added to the traditional single-leg hop tests to provide a more ecologically valid test that incorporates the integration of physical and cognitive function for return to sport. The test–retest reliability of the 4 new neurocognitive hop tests is highly reliable and does not change systematically. [ABSTRACT FROM AUTHOR]

Context: Individuals who sustain a knee surgery have been shown to have an increased likelihood to develop osteoarthritis (OA). Objective: Identify the consequences of knee surgery in a cohort of former college athletes. Design: Cross-sectional. Setting: Research laboratory. Participants: A group of 100 former Division I college athletes aged 40–65 years (60 males and 40 females) participated in the study. Interventions: All individuals self-reported whether they sustained a knee injury during college requiring surgery and if they have been diagnosed with knee OA by a medical physician post knee injury. Individuals were categorized into 3 groups: no history of knee injury requiring surgery (33 males and 24 females; 54.53 [5.95] y), history of knee surgery in college with no diagnosis of OA later in life (4 males and 6 females; 51.26 [7.29] y), and history of knee surgery in college with physician diagnosed OA later in life (23 males and 10 females; 54.21 [7.64] y). All individuals completed the knee injury and osteoarthritis outcome score (KOOS) and short form-36 version 2. Main Outcome Measures: Scores on the KOOS and short form-36 version 2. Results: A majority (76.7%) of individuals who had a knee surgery in college did develop OA. The largest mean differences were between the healthy knee and surgical knee/OA groups on the KOOS-quality of life scale (mean difference: 49.76; χ2(3) = 44.65; P <.001) and KOOS-sports scale (mean difference: 43.69; χ2(3) = 28.69; P <.001), with the surgical knee/OA group scoring worse. Conclusions: Later in life functional limitations were observed in individuals who sustained a knee injury requiring surgery and developed OA. These findings support increased efforts toward prevention of knee injuries and consideration of the long-term implication when making treatment and return to activity decisions. [ABSTRACT FROM AUTHOR]

OBJECTIVE Inadequate evidence, position statements, clinical practice and post-surgical guidelines challenge athletic trainers’ capabilities to provide care for abdominal injuries and GI conditions. The primary objective of this study is to assess athletic trainers’ confidence in the management and treatment of abdominal injuries and GI conditions compared to musculoskeletal injuries. STUDY DESIGN An online cross-sectional survey randomly distributed to 1000 potential participants using the NATA Research Survey Service. PARTICIPANTS Forty-four certified athletic trainers (mean age 39.26 ± 11.73 years), representing various NATA districts and practice settings finished the survey (response rate: ~5%). INTERVENTION Survey items were adapted from studies that evaluated confidence in the management of injuries/conditions and from athletic training educational competencies. Survey items included demographic data, confidence (5-point Likert scale) in education and clinical skills, knowledge obtainment, and need for resources pertaining to the care of musculoskeletal injuries, abdominal injuries, and GI conditions. MAIN.OUTCOME.MEASURES Descriptive statistics were calculated for each survey item. Descriptive statistics were used to evaluate athletic trainers’ consensus on a need for more resources. A Friedman non-parametric one- way repeated-measures ANOVA was used to evaluate the difference in confidence items between abdominal injuries, GI conditions, and musculoskeletal injuries (within subjects factor). Dependent variables included confidence levels in education and clinical skills. Chi-square (χ2) tests of independence were used to evaluate the influence of descriptive characteristics on confidence levels (for abdominal injuries and GI conditions). Alpha level was set at 0.05 for all analyses. RESULTS There were significant differences in confidence in education (χ²(2)= 52.619, p < 0.001), ability to design therapeutic interventions (χ²(2) = 52.619, p < 0.001), and ability to make RTP decisions (χ²(2)= 48.549, p < 0.001). Confidence for abdominal injuries and GI conditions was lower than musculoskeletal injuries (median rank difference = 1.0 to 2.0 points). The same was observed for conditions that require surgery for confidence in education (χ²(2)= 59.210, p < 0.001), ability to design therapeutic interventions (χ²(2)= 48.982, p < 0.001), and ability to make RTP decisions (χ²(2)= 57.796, p < 0.001; median rank difference = 2.0 points). Most agreed or strongly agreed that there is a need for more knowledge in education programs (70.5%), resources and continuing education (79.5%), and guidelines (81.8%) for abdominal injuries and GI conditions. CONCLUSIONS Compared to traditional musculoskeletal injuries, athletic trainers display significantly lower levels of confidence in their education, ability to design therapeutic interventions, and ability to make RTP decisions for abdominal injuries and GI conditions. There is a need for further studies, resources, and standard guidelines on this topic to better support athletic trainers’ confidence and to provide athletes with better recovery outcomes. [ABSTRACT FROM AUTHOR]

Background: Anterior cruciate ligament (ACL) rupture is a common knee injury among athletes and physically active adults. Despite surgical reconstruction and extensive rehabilitation, reinjuries are common and disability levels are high, even years after therapy and return to activity. Prolonged knee dysfunction may result in part from unresolved neuromuscular deficits of the surrounding joint musculature in response to injury. Indeed, "upstream" neurological adaptations occurring after injury may explain these persistent functional deficits. Despite evidence for injury consequences extending beyond the joint to the nervous system, the link between neurophysiological impairments and patient-reported measures of knee function remains unclear. Hypothesis: Patterns of brain activation for knee control are related to measures of patient-reported knee function in individuals after ACL reconstruction (ACL-R). Study Design: Cross-sectional study. Level of Evidence: Level 3. Methods: In this multicenter, cross-sectional study, participants with unilateral ACL-R (n = 25; 10 men, 15 women) underwent task-based functional magnetic resonance imaging testing. Participants performed repeated cycles of open-chain knee flexion/extension. Neural activation patterns during the movement task were quantified using blood oxygen level–dependent (BOLD) signals. Regions of interest were generated using the Juelich Histological Brain Atlas. Pearson product-moment correlations were used to determine the relationship between mean BOLD signal within each brain region and self-reported knee function level, as measured by the International Knee Documentation Committee index. Partial correlations were also calculated after controlling for time from surgery and sex. Results: Patient-reported knee function was positively and moderately correlated with the ipsilateral secondary somatosensory cortex (r = 0.57, P = 0.005) and the ipsilateral supplementary motor area (r = 0.51, P = 0.01). Conclusion: Increased ipsilateral secondary sensorimotor cortical activity is related to higher perceived knee function. Clinical Relevance: Central nervous system mechanisms for knee control are related to subjective levels of knee function after ACL-R. Increased neural activity may reflect central neuroplastic strategies to preserve knee functionality after traumatic injury. [ABSTRACT FROM AUTHOR]

With 8 million annual US high school student-athletes, the epidemiology of sport-related injuries has garnered significant interest. The most recent studies examining overuse injury rates in high school sports were based on data from 2012 to 2013 and, therefore, may not reflect current overuse injury rates in high school sports. To (1) determine overuse time-loss (TL) and non–time-loss (NTL) injury rates among high school student-athletes using National Athletic Treatment, Injury and Outcomes Network Surveillance Program (NATION-SP) data collected from 2014–2015 to 2018–2019 and (2) compare overuse injury rates based on student-athlete sex defined by whether it was a boys' sport or a girls' sport, the sport itself, and the injury location. Descriptive epidemiology study. Online injury surveillance from 211 high schools (345 individual years of high school data). Athletes who participated in secondary school–sponsored boys' or girls' sports. Boys' and girls' overuse injury data from the NATION-SP during the 2014–2015 to 2018–2019 school years were analyzed. Overuse injuries were identified using a combination of the reported injury mechanism and diagnosis. Time-loss injuries resulted in restriction from participation beyond the day of injury; NTL injuries did not result in restriction from participation beyond the day of injury or involved no lost time due to the injury. Injury counts, rates, and rate ratios (IRRs) were reported with 95% CIs. The total overuse injury rate was 5.3/10 000 athlete-exposures (AEs; 95% CI = 5.1, 5.7), the NTL overuse injury rate was 3.4/10 000 AEs (95% CI = 3.1, 3.6), and the TL overuse injury rate was 2.0/10 000 AEs (95% CI = 1.8, 2.2). The overuse injury rate was greater in girls' sports compared with boys' sports (IRR = 1.9; 95% CI = 1.7, 2.1). The highest rates of overuse injury were observed in girls' cross-country (19.2/10 000 AEs; 95% CI = 15.0, 24.2), girls' track and field (16.0/10 000 AEs; 95% CI = 13.5, 18.8), and girls' field hockey (15.1/10 000 AEs; 95% CI = 10.2, 21.6). Overuse injury rates were higher for the lower extremity than the upper extremity (IRR = 5.7; 95% CI = 4.9, 6.7) and for the lower extremity than the trunk and spine (IRR = 8.9; 95% CI = 7.3, 10.8). Awareness of the overuse injury risk, as well as prevention and intervention recommendations, is necessary and should be specifically targeted at cross-country, field hockey, and track and field athletes. [ABSTRACT FROM AUTHOR]

Socioeconomic status (SES) is a significant predictor of morbidity and mortality across health outcomes. Limited information exists on how school SES affects athletic training practice when a certified athletic trainer (AT) is present at secondary schools. To describe contact frequencies and service rates provided by ATs for injuries among secondary school student-athletes and how these differ by school SES. Cross-sectional study. The number of athletic training facility (ATF) visit days and AT services were collected from 77 secondary schools. Schools were separated into 3 school SES groups: affluent (n = 31), average (n = 29), and disadvantaged (n = 17). Secondary school student-athletes who participated in ≥1 of 12 boys' or 11 girls' sports, visited the ATF during the 2014–2015 through 2018–2019 academic years, and received athletic or nonathletic injury care. Contact frequencies were expressed as ATF visit days per injury, AT services per injury, and AT services per ATF visit day. Rates for service type used were expressed as the total count over reported athlete-exposures. The ATs documented 1191 services. Affluent and average SES school communities provided more contact frequencies for injury-related care than did disadvantaged school communities, particularly in AT services per injury (7.10 ± 13.08 versus average: 9.30 ± 11.60 and affluent: 9.40 ± 12.20; P =.020). Affluent school communities supplied greater rates of services in 5 of the 11 service groups reported. No differences were observed among school SES groups in therapeutic exercise. Our findings reflect that AT practice characteristics may have differed by school SES, but these differences did not appear to result in less medical care. Given the complexity and widespread effects of SES, future investigators should use a complex method to determine SES and aim to identify how SES may affect secondary school student-athletes in ways other than AT practice characteristics. [ABSTRACT FROM AUTHOR]

Visual cognitive ability has previously been associated with anterior cruciate ligament injury and injury risk biomechanics in healthy athletes. Neuroimaging reports have identified increased neural activity in regions corresponding to visual‐spatial processing, sensory integration, and visual cognition in individuals after anterior cruciate ligament reconstruction (ACLR), indicating potential neural compensatory strategies for motor control. However, it remains unclear whether there is a relationship between visual cognition, neural activity, and metrics of neuromuscular ability after ACLR. The purpose of this study was to (1) evaluate the relationship between visual cognitive function and measurements of neuromuscular control (proprioception and time to stability [TTS]), isokinetic strength, and subjective function, and (2) examine the neural correlates of visual cognition between ACLR (n = 16; time since surgery 41.4 ± 33.0 months) and demographically similar controls (n = 15). Visual cognition was assessed by the ImPACT visual motor and visual memory subscales. Outcome variables of proprioception to target knee angle 20°, landing TTS, strength, and subjective function were compared between groups, and visual cognition was correlated within groups to determine the relationship between visual cognition and outcome variables controlled for time from surgery (ACLR group). The control group had better IKDC scores and strength. Visual memory and visual motor ability were negatively associated with proprioception error (r = −0.63) and TTS (r = −0.61), respectively, in the ACLR group but not controls. Visual cognition was associated with increased neural activity in the precuneus and posterior cingulate cortex in the ACLR group but not control participants. These data suggest the neural strategy in which ACLR participants maintain proprioception and stability varies, and may depend on visual cognition and sensory integration neural activity. [ABSTRACT FROM AUTHOR]

Minimal clinically important differences (MCIDs) are used to understand clinical relevance. However, repeated observations produce biased analyses unless one accounts for baseline observation, known as regression to the mean (RTM). Using an International Knee Documentation Committee (IKDC) survey dataset, we can demonstrate the effect of RTM on MCID values by (1) MCID-estimate dependence on baseline observation and (2) MCID-estimate bias being higher when the posttest-pretest data correlation is lower. We created 10 IKDC datasets with 5000 patients and a specific correlation under both equal and unequal variances. For each 10-point increase in baseline IKDC, MCID decreased by 3.5, 2.7, 1.9, 1.2, and 0.7 points when posttest-pretest correlations were 0.10, 0.25, 0.50, 0.75, and 0.90, respectively, under equal variances. Not accounting for RTM resulted in a static 20-point MCID. Minimal clinically important difference estimates may be unreliable. Minimal clinically important difference calculations should include the correlation and variances between posttest and pretest data, and researchers should consider using a baseline covariate-adjusted receiver operating characteristic curve analysis to calculate MCID. [ABSTRACT FROM AUTHOR]