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BACKGROUND The anterior cruciate ligament quality of life (ACL-QOL) score is a disease-specific patient-reported outcome measure that assesses patients with ACL deficient and reconstructed knees. The ACL-QOL has demonstrated validity, responsiveness, and reliability in adult populations but has yet to be specifically evaluated in adolescent patients. The purpose of this study was to assess the validity, responsiveness, and reliability of the ACL-QOL in an adolescent population. METHODS Between 2010 and 2015, questionnaires from 294 consecutive adolescent patients consented for an ACL reconstruction were collected from an orthopaedic sport medicine clinic. The ACL-QOL was administered preoperatively, and at 6, 12, and 24 months following primary ACL reconstruction. To assess content validity, the Cronbach α and floor and ceiling effects were measured. Question reading level was measured with an online tool (https://readable.com/). Responsiveness was assessed with a 1-way analysis of variance to compare the preoperative and postoperative time periods. A test-retest strategy with completion of the ACL-QOL twice within 3 weeks was used to assess reliability using an intraclass correlation coefficient (ICC 2,k) and the SEM. RESULTS The ACL-QOL demonstrated high content validity with a Cronbach αbetween 0.93 and 0.97, with no evidence of floor or ceiling effects at any study time point. The mean readability grade level was calculated to be 6.9, along with a readability score of 68. The ACL-QOL scores revealed a statistically significant improvement over time (P

Purpose The purpose of this study was to assess the inter-rater reliability of 3 common physical examination assessments, the Q-angle, J-sign, and apprehension test, used to evaluate patients presenting with recurrent lateral patellofemoral instability. Methods A consecutive sample of 38 subjects with recurrent lateral patellofemoral instability in 2013 were included in this reliability study. Two orthopaedic surgeons performed the physical examination maneuvers blinded to each other. The physical examination tests were performed bilaterally and included the Q angle, the J-sign, and the apprehension test. To measure the inter-rater reliability, an intraclass correlation coefficient (ICC 2,κ) was used for both legs independently for Q-angle measurements. A Cohen’s kappa was used to measure the inter-rater reliability for the J-sign and the apprehension test. Results The measurement of the Q-angle demonstrated poor reliability (ICC 2,κ 0.18-0.44). The assessment of the J-sign demonstrated fair to moderate reliability (κ = 0.31 – 0.41), and the evaluation of apprehension demonstrated fair to substantial reliability (κ = 0.30 – 0.65). All 3 clinical tests demonstrated substantial variability comparing the reliability on the right and left limbs. Assessment of the quality of apprehension demonstrated good agreement between the examiners. Conclusions In this study of patients with recurrent lateral patellofemoral instability the common physical examination tests, Q-angle, J-sign, and apprehension demonstrated weak inter-rater reliability. These results indicate that these tests are not reliable for communication between health care practitioners or as evaluations for clinical research. Level of Evidence Level IV, therapeutic case series.

Context Competency-based education (CBE) is entrenched in educating health professionals in Canada. CBE is a framework that identifies desired performance characteristics in training competent, entry-level health professionals. Objective To update, develop, and validate a new Canadian Athletic Therapists Association (CATA) framework for athletic therapy education. Design Framework development occurred in 4 phases and was developed through a multistage process that involved a scoping review (phase 1) and consensus methodology (ie, a blending of modified Ebel and modified Delphi consensus methods; phases 2–4). Patients or Other Participants Phase 2: a total of 7 experts (program directors) from each Canadian accredited institution. Phase 3: a total of 14 experts (1 program director and educational expert from each accredited institution). Phase 4: a total of 7 experts (program directors) and 246 certified members of the CATA. Main Outcome Measure(s) Each phase consisted of a systematic process with 80% consensus agreement set a priori. In phase 1, a scoping review was conducted to identify common terminology that could be used to guide the framework development process and to identify competency frameworks used by other health professional organizations. Phase 2 consisted of adopting a common language that would serve to keep the expert group on the task at hand and avoid confusion. In phase 3, frameworks used by other health professional organizations were evaluated and used to determine the validity of the old CATA framework. In phase 4, the old CATA framework was updated and a new framework was developed and validated. Results In phase 1, the result of the scoping review yielded 368 papers, of which 5 were used to propose a common language for phase 2 and 9 highlighted competency frameworks used by other health professions for comparison in phase 3. In phase 3, the expert group voted unanimously to adopt and adapt the CanMEDS framework (ie, roles). In phase 4, the new CATA competency framework was validated, and most competencies achieved consensus. Competencies that did not achieve consensus in the first round of voting underwent face-to-face discussions via videoconferencing. After discussions, the remaining competencies were revised, and all newly worded competencies achieved consensus. Conclusions The resultant framework was validated, and most competencies achieved consensus. The new athletic therapy competency framework outlines the 165 competencies resulting from this methodical process and will hopefully facilitate interdisciplinary communication and practice.

The primary purpose of this study was to determine if isolated medial patellofemoral ligament (MPFL) reconstruction for lateral patellofemoral instability altered the patellar height ratio. Secondary purposes were to use disease-specific quality-of-life scores to determine if MPFL reconstruction is as successful in patients with patella alta, compared to those without; and whether the change in the patellar height ratio after MPFL reconstruction is influenced by demographic and clinical factors. Demographic and clinical data were collected pre-operatively on 283 patients with recurrent patellofemoral instability. Pre-operative and 6-month post-operative true-lateral radiographs were assessed to determine the patellar height ratio using the Caton-Deschamps index. A Caton-Deschamps index ≥ 1.2 was defined as patella alta. Paired t tests evaluated the effect of MPFL reconstruction on the Caton-Deschamps index. Using a two-sample t test, pre- and 24-month post-operative Banff Patellofemoral Instability Instrument (BPII) scores were assessed for differences in clinical outcomes between patients with and without patella alta. Pearson (for continuous variables) and Spearman rank correlations (for binary/ordinal variables) were calculated to determine the relationship between the patellar height ratio, demographic and pathoanatomic risk factors, and pre- and post-operative BPII scores. Pre- and post-operative true-lateral radiographs were admissible for 229/283 patients (81%) following isolated MPFL reconstruction. A statistically significant difference in the Caton-Deschamps index was evident from pre- to post-operative for the entire cohort (p

Background: Multiple studies have demonstrated that a number of demographic and pathoanatomic characteristics are associated with patellofemoral instability, recurrence of instability, and less satisfactory results following medial patellofemoral ligament reconstruction (MPFL-R). Despite the growing volume of research, the relationship of risk factors to patient-reported outcome after MPFL-R is unclear. Purpose: To determine if certain pathoanatomic and demographic factors predict disease-specific quality-of-life outcome after isolated MPFL-R for symptomatic patellofemoral instability. Study Design: Cohort study; Level of evidence, 3. Methods: The study analyzed 224 isolated MPFL-Rs. Demographic data were collected, including age at first dislocation, sex, and presence of bilateral instability. Pathoanatomic risk factors included the presence of high-grade trochlear dysplasia, tibial tubercle–trochlear groove (TT-TG) distance, patella alta ratio, Beighton score, and patellar tilt. Other factors included femoral tunnel position accuracy and WARPS/STAID score. Descriptive analyses were conducted, followed by calculation of individual Spearman rank correlation coefficients for the predictor variables versus the Banff Patellofemoral Instability Instrument (BPII) scores. A multivariable regression with stepwise selection was employed to establish the final model predicting BPII score, with all significant variables for alpha ≤ .05 included in the final model. Results: The cohort of 224 patients included 66 (29.5%) males and 158 (70.5%) females, with a mean age of 24.1 years and a mean body mass index of 23.9 kg/m2. The mean age of first patellar dislocation was 15.7 years, and 41.4% of patients had bilateral instability. Pathoanatomic variables within the cohort included the following: high-grade trochlear dysplasia = 41%; mean TT-TG = 14.6 mm, with 16.8% of patients demonstrating a TT-TG ≥18 mm; mean Caton-Deschamps ratio = 1.09, with 22% of patients demonstrating a ratio ≥1.2; and positive Beighton score = 37.5%. The mean BPII score at postoperative 2 years was 67.1 out of 100. A stepwise elimination in the regression model demonstrated no statistically significant 3- or 2-way relationships. Assessment of individual variables indicated that bilateral symptoms ( P = .004), higher age at first dislocation ( P = .024), and femoral tunnel position >10 mm from the Schöttle point ( P = .042) were statistically significant predictors of lower quality-of-life scores. The R2 value for the regression analysis model was 0.07. Conclusion: In this large cohort of patients undergoing isolated MPFL-R for symptomatic lateral patellofemoral instability, a multivariable forward stepwise regression demonstrated that bilateral symptoms, femoral tunnel position, and age at first dislocation were statistically significant predictors of lower postoperative BPII scores. No anatomic risk factors were predictive of quality-of-life outcome score 2 years after MPFL-R surgery. The R2 value indicated that there were many other important contributing factors affecting BPII outcome scores than those explored in this study.

Generalized joint hypermobility (GJH) has frequently been described as a risk factor for patellofemoral instability; however, only a few primary research studies have demonstrated any evidence of a relationship. The primary purpose of this study was to determine if isolated proximal soft tissue stabilization for patellofemoral instability is as successful in patients with GJH compared those without, as measured by disease-specific quality-of-life (QOL), symptom scores and functional outcomes. The secondary purpose was to determine if clinical and patient-reported outcomes were influenced by patient demographic factors in the presence of joint hypermobility. Between 2009 and 2014, data were collected on 174/193 knees (92% follow-up) following an isolated medial patellofemoral ligament reconstruction (MPFL-R). Patients with a Beighton score of 4 or greater were classified as positive for GJH, and any score of 3 or less was classified as negative. Pre- and post-operative Banff Patella Instability Instrument (BPII) scores were compared using a two-sample t test to determine the influence of GJH on QOL. The relationship between the Beighton score, and demographic and clinical factors was explored using correlational analysis. Functional testing including balance and single-leg hop testing was conducted 1 and 2 years post-operatively. Limb symmetry and mean limb-to-limb performance differences were calculated. In this cohort of isolated MPFL reconstructions, 55.1% had a positive Beighton score. There were seven surgical failures (3.6%). There was no evidence of a relationship between a positive Beighton score and pre-operative BPII scores, post-operative BPII scores or post-operative symptom scores. GJH did not correlate significantly with any post-operative functional testing measures. A positive Beighton score was inversely related to patient age and more prevalent in females. This study determined that the presence of GJH did not influence disease-specific quality of life, physical symptom score or functional outcomes following MPFL reconstruction. III.

Background: The clinical sign of patellar laxity and the associated symptom of apprehension are mainstays of the physical examination of patellofemoral instability. The apprehension test is widely used as a diagnostic tool and also as an outcome following patellofemoral stabilization surgery. Despite widespread use, the validity, reliability, and responsiveness of the apprehension test have not been established. Purpose: The primary purpose was to evaluate patellar apprehension in patients with recurrent patellofemoral instability to determine if the apprehension test is valid, reliable, and responsive to change after medial patellofemoral ligament (MPFL) reconstruction. The secondary purposes were to concurrently validate patient-rated to surgeon-rated apprehension and to correlate patient-rated apprehension with pathoanatomic characteristics and quality-of-life scores. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A total of 89 patients underwent an MPFL reconstruction and were assessed preoperatively and at 6, 12, and 24 months postoperatively. The patellar apprehension test was performed in neutral extension and 30° of knee flexion. Patient- and surgeon-rated apprehension were graded on a 10-cm visual analog scale (VAS), and the quality of the apprehension symptoms were recorded. Risk factors for patellofemoral instability were documented, and the Banff Patellofemoral Instability Score 2.0 (BPII 2.0) was used to measure disease-specific quality of life. Results: The patient-rated and surgeon-rated apprehension VAS scores were statistically significantly reduced from pre- to postoperatively ( P < .001, large effect size) for the neutral extension and 30° of flexion apprehension tests. Postoperatively, over 56% of patients reported a negative apprehension test. Up to 15.7% of patients with positive preoperative apprehension did not demonstrate a reduction postoperatively. Patients consistently graded their apprehension symptoms higher in both quantity and quality than the surgeon. The intraclass correlation coefficient (ICC [2, k]) assessing the preoperative patient and surgeon VAS scores revealed moderate interrater reliability in neutral extension ( r = 0.60) and weak interrater reliability in 30° of flexion ( r = 0.42). The postoperative ICC (2, k) demonstrated strong interrater reliability for both neutral extension ( r = 0.74) and 30° of flexion ( r = 0.73). The symptoms of apprehension (physical, emotional, and/or physiological) decreased substantially after surgery. The correlation of postoperative patient-rated apprehension VAS and BPII 2.0 scores demonstrated that less residual patellar apprehension was associated with higher BPII scores in neutral extension ( r = −0.35, P = .001). There were no statistically significant correlations revealed between the patient-rated postoperative apprehension VAS and pathoanatomic risk factors. BPII 2.0 scores improved pre- to postoperatively from a mean of 27.6 (SD, 15.7) to 74.3 (SD, 18.3). Three patients (3.4%) sustained a patellar dislocation postoperatively. Conclusion: The patellar apprehension test demonstrated strong validity and responsiveness to change. Interrater reliability ranged from weak to strong. There was a statistically significant reduction in apprehension after patellofemoral stabilization in the majority of patients. Patients graded their apprehension symptoms significantly higher in both quantity and quality than the surgeon. Persistent patellar apprehension after stabilization was correlated with lower quality-of-life scores. No relationship could be found between persistent apprehension and patellofemoral risk factors. These results suggest that use of the apprehension tests as an outcome is inappropriate until further validation is performed.

Early childhood education and care (ECEC) environments influence children’s early development and habits that track across a lifespan. The purpose of this study was to explore the impact of COVID-19 government-mandated guidelines on physical activity (PA) and eating environments in ECEC settings. This cross-sectional study involved the recruitment of 19 ECEC centers pre-COVID (2019) and 15 ECEC centers during COVID (2020) in Alberta, Canada (n = 34 ECEC centers; n = 83 educators; n = 361 preschoolers). Educators completed the CHEERS (Creating Healthy Eating and activity Environments Survey) and MEQ (Mindful Eating Questionnaire) self-audit tools while GT3X+ ActiGraph accelerometers measured preschooler PA. The CHEERS healthy eating environment subscale was greater during COVID-19 (5.97 ± 0.52; 5.80 ± 0.62; p = 0.02) and the overall score positively correlated with the MEQ score (r = 0.20; p = 0.002). Preschoolers exhibited greater hourly step counts (800 ± 189; 649 ± 185), moderate-to-vigorous PA (MVPA) (9.3 ± 3.0 min/h; 7.9 ± 3.2 min/h) and lower sedentary times (42.4 ± 3.9 min/h; 44.1 ± 4.9 min/h) during COVID-19 compared to pre-COVID, respectively (p < 0.05). These findings suggest the eating environment and indices of child physical activity were better in 2020, which could possibly be attributed to a change in government-mandated COVID-19 guideline policy.

Trochlear dysplasia is a well-described risk factor for recurrent patellofemoral instability. Despite its clear association with the incidence of patellofemoral instability, it is unclear whether the presence of high-grade trochlear dysplasia influences clinical outcome after patellofemoral stabilization. The purpose of this study was to assess whether trochlear dysplasia influenced patient-reported, disease-specific outcomes in surgically treated patellar instability patients, when risk factors were addressed in accordance with the à la carte surgical approach to the treatment of patellofemoral instability. The study design is of a case series. A total of 318 patellar stabilization procedures were performed during the study period. Of these procedures, 260 had adequate lateral radiographs and complete Banff Patellar Instability Instrument (BPII) scores available for assessment. A Pearson r correlation was calculated between four characteristics of trochlear dysplasia, the BPII total and the BPII symptoms, and physical complaints scores, a mean of 24 months following patellofemoral stabilization. Independent t-tests were performed between stratified trochlear dysplasia groups (no/low grade and high grade) and all BPII measures. There was a statistically significant correlation between measures of trochlear dysplasia and quality-of-life physical symptoms scores, an average of 2 years following patellofemoral stabilization surgery. The BPII symptoms and physical complaints domain score, as well as the individual weakness and stiffness questions, correlated with the classification of trochlear dysplasia as well as the presence of a trochlear bump (p

The purpose of this study was to assess the accuracy of femoral tunnel placement in a medial patellofemoral ligament reconstruction (MPFL-R) cohort. The secondary purpose was to establish the evidence of a learning curve to achieve acceptable femoral tunnel placement during MPFL-R. Two surgeons, using lateral radiographs, assessed 73 subjects post–MPFL-R. Femoral tunnel accuracy and direction of tunnel error were measured in relation to Schöttle's point (A–T distance). Interrater reliability (intraclass correlation coefficient 2,k) of these measures was calculated. Learning curve of accurate femoral tunnel placement was examined by dividing the patient cohort into quartiles. A one-way analysis of variance was used to assess the quartiles for accuracy of femoral tunnel position and surgical time. In relation to Schöttle's point, 66/73 (90.4%) femoral tunnels were categorized as being in a “good” or “excellent” position and 7/73 (9.6%) were categorized as being in a “poor” position. Evidence of an MPFL-R learning curve was established via a statistically significant difference in the mean A to T distance for the four quartiles (F [3, 69] = 6.41, p = 0.001). There was also a statistically significant difference in the surgical time for the four quartiles (F [3, 69] = 8.71, p = 0.001). In this series, accurate femoral tunnels were placed more than 90% of the time during MPFL-R. A clear learning curve for accurate femoral tunnel placement was demonstrated both with respect to distance of the tunnel from Schöttle point and with regard to surgical time. Level of evidence was IV.

Background The Rotator Cuff Quality of Life Index (RC-QOL) was developed to evaluate quality of life in patients with rotator cuff disorders (RCD). The purpose of this study was to provide additional reliability, validity, and responsiveness testing in accordance with the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines. Methods Preliminary patient interviews included 15 patients. Seventy patients (mean age, 58; standard deviation, 9 years) with RCD were evaluated. Methodology testing included internal consistency, test-retest reliability, measurement error, content validity, and construct validity. Responsiveness, interpretability, and generalizability were also analyzed. Results The Cronbach α was 0.96 (95% confidence interval, 0.89-0.99; range, 0.72-0.94). The intraclass correlation coefficient for the RC-QOL was 0.87 (95% confidence interval, 0.79-0.85; range, 0.77-0.88). The standard error of measurement was 8 (range, 7-13). The smallest detectable change was 3 (range, 2-4). Content validity was confirmed through standardized patient interviews. All a priori hypotheses were confirmed. No floor or ceiling effects were present. The minimally clinical important difference ranged between 7 and 14 points. The study met the COSMIN criteria for interpretability and generalizability. Conclusion The RC-QOL is a reliable and valid measure of health-related quality of life in patients with chronic RCD. The results of this study added to the methodologic quality assessment of the RC-QOL, completing 7 of 10 COSMIN criteria.

BACKGROUND AND OBJECTIVES Currently, management of patients presenting with chronic rotator cuff tears in Alberta is in need of quality improvements. This article explores the potential impact of a proposed care pathway whereby all patients presenting with chronic rotator cuff tears in Alberta would adopt an early, conservative management plan as the first stage of care; ultrasound investigation would be the preferred tool for diagnosing a rotator cuff tear; and only patients are referred for surgery once conservative measures have been exhausted. METHODS We evaluate evidence in support of surgery and conservative management, compare care in the current state with the proposed care pathway, and identify potential solutions in moving toward optimal care. RESULTS A literature search resulted in an absence of indications for either surgical or conservative management. Conservative management has the potential to reduce utilization of public health care resources and may be preferable to surgery. The proposed care pathway has the potential to avoid nearly Can $87 000 in public health care costs in the current system for every 100 patients treated successfully with conservative management. CONCLUSION The proposed care pathway is a low-cost, first-stage treatment that is cost-effective and has the potential to reduce unnecessary, costly surgical procedures.

The primary purpose of this study was to determine if isolated medial patellofemoral ligament (MPFL) reconstruction for lateral patellofemoral instability altered the patellar height ratio. Secondary purposes were to use disease-specific quality-of-life scores to determine if MPFL reconstruction is as successful in patients with patella alta, compared to those without; and whether the change in the patellar height ratio after MPFL reconstruction is influenced by demographic and clinical factors.Demographic and clinical data were collected pre-operatively on 283 patients with recurrent patellofemoral instability. Pre-operative and 6-month post-operative true-lateral radiographs were assessed to determine the patellar height ratio using the Caton-Deschamps index. A Caton-Deschamps index ≥ 1.2 was defined as patella alta. Paired t tests evaluated the effect of MPFL reconstruction on the Caton-Deschamps index. Using a two-sample t test, pre- and 24-month post-operative Banff Patellofemoral Instability Instrument (BPII) scores were assessed for differences in clinical outcomes between patients with and without patella alta. Pearson (for continuous variables) and Spearman rank correlations (for binary/ordinal variables) were calculated to determine the relationship between the patellar height ratio, demographic and pathoanatomic risk factors, and pre- and post-operative BPII scores.Pre- and post-operative true-lateral radiographs were admissible for 229/283 patients (81%) following isolated MPFL reconstruction. A statistically significant difference in the Caton-Deschamps index was evident from pre- to post-operative for the entire cohort (p 0.001). The mean decrease in ratio was 0.03, and the effect size was 0.27, classified as small. Pre-operatively 52/229 patients (22.7%) demonstrated a Caton-Deschamps index ≥ 1.2, mean = 1.27 (SD = 0.08); post-operatively 21/229 patients (9.2%) demonstrated patella alta, mean = 1.18, (SD = 0.10), p 0.001 (two-tailed). The mean decrease in the Caton-Deschamps index for patients with pre-operative patella alta was 0.10; the effect size was 0.82, classified as large. Pearson r correlation of patella alta to the pre- and post-operative BPII scores demonstrated no statistically significant relationship.This study has demonstrated that treatment of lateral patellofemoral instability with an isolated MPFL reconstruction results in a statistically significant decrease in patellar height ratio, with the effect size being greatest in patients with higher pre-operative Caton-Deschamps indices. In patients that presented with patella alta, normalization of the patellar height ratio occurred in 31/52 (59.6%) of the cases. Pre-operative patella alta was not associated with a statistically significant difference in disease-specific BPII outcome scores at any time point. Given these findings, the utility and results of tibial tubercle distalization in patients with patella alta should be a focus of further research. Level of evidence IV.

Background:Patellofemoral instability is a common knee problem that is difficult to manage owing to its multifactorial etiology as well as the fact that predisposing pathoanatomic features vary from individual to individual. There is limited knowledge regarding the demographic and pathoanatomic risk factors or the relationship between these risk factors and the redislocation rate after surgical stabilization for this challenging condition.Purpose:To analyze the postoperative redislocation rates and the prevalence of demographic and pathoanatomic risk factors for patients undergoing a patellofemoral stabilization.Study Design:Case series; Level of evidence, 4.Methods:Patients with symptomatic recurrent patellofemoral instability underwent a soft tissue patellofemoral stabilization procedure. A total of 342 patellofemoral stabilization procedures (reconstruction, n = 256; imbrication, n = 86) were assessed at a mean follow-up of 24.3 months. Concomitant procedures were performed in accordance with the à la carte concept of addressing significant anatomic or biomechanical characteristics. Two surgical cohorts were analyzed separately for reconstruction or imbrication to address laxity of the medial patellofemoral ligament (MPFL). Failure of the patellofemoral stabilization procedure was defined as postoperative redislocation of the patella. Prevalence of demographic and pathoanatomic risk factors was determined for all patients. Disease-specific patient-reported outcomes were assessed with the Banff Patella Instability Instrument (BPII).Results:A redislocation rate of 5.1% was identified for MPFL reconstruction and 20.9% for MPFL imbrication. For both MPFL procedures, age at time of surgery was significantly younger for the failed group as compared with the intact group. Postoperative BPII scores were significantly lower for patients who subsequently experienced a surgical failure as compared with intact surgery for both MPFL reconstruction ( P = .048) and MPFL imbrication ( P = .003).Conclusion:Patellofemoral stabilization with an à la carte approach to surgical selection demonstrated a low postoperative redislocation rate and good clinical results. Younger age at time of surgery was associated with surgical failure. This information may be used to guide surgical decision making and patient education.

BACKGROUND Lateral patellofemoral instability is a relatively common problem in the adolescent population. Subjective and objective patient outcomes are commonly used to evaluate treatment success or failure. The Banff Patellofemoral Instability Instrument (BPII) and Paediatric International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Form are patient-reported outcome measures that have been used with an adolescent population previously. The BPII 2.0 is a shortened version of the BPII and has not been validated in an adolescent population. The purpose of the current study was to validate the BPII 2.0 with an adolescent population. METHODS This was a multicenter study where patients were recruited from 3 tertiary orthopaedic surgery clinics. A convenience sample (n=140 adolescent patients) with a confirmed diagnosis of lateral patellofemoral instability and who had failed conservative treatment was referred to one of the 3 orthopaedic surgeons. All patients completed the BPII 2.0 and Pedi-IKDC before their clinic appointment. Cronbach's alpha and floor/ceiling effects were used to determine the content validity of both instruments. Patients were also interviewed to ask questions about the BPII 2.0 comprehension and importance of items. One clinic site sent out the BPII 2.0 to 30 additional patients twice in 2 weeks to measure the test-retest reliability (intraclass correlation coefficient 2,k). A Pearson r correlation coefficient was used to determine the relationship between the BPII 2.0 and the Pedi-IKDC and criterion validity. RESULTS Cronbach's alpha values were 0.95 and 0.76 for the BPII 2.0 and Pedi-IKDC, respectively. There was no evidence of floor or ceiling effects for either the BPII 2.0 or the Pedi-IKDC. The Pearson r correlation coefficient between the BPII 2.0 and IKDC baseline scores taken at the initial consultation was 0.65 (P

The WARPS/STAID classification employs clinical assessment of presenting features and anatomic characteristics to identify two distinct subsets of patients within the patellofemoral instability population. The purpose of this study was to further define the specific demographics and the prevalence of risky pathoanatomies in patients classified as either WARPS or STAID presenting with recurrent patellofemoral instability. A secondary purpose was to further validate the WARPS/STAID classification with the Banff Patella Instability Instrument (BPII), the Marx activity scale and the Patellar Instability Severity Score (ISS). A convenience sample of 50 patients with recurrent patellofemoral instability, including 25 WARPS and 25 STAID subtype patients, were assessed. Clinical data were collected including assessment of demographic risk factors (sex, BMI, bilaterality of symptoms, affected limb side and age at first dislocation) and pathoanatomic risk factors (TT-TG distance, patella height, patellar tilt, grade of trochlear dysplasia, Beighton score and rotational abnormalities of the tibia or femur). Patients completed the BPII and the Marx activity scale. The ISS was calculated from the clinical assessment data. Patients were stratified into the WARPS or STAID subtypes for comparative analysis. An independent t test was used to compare demographics, the pathoanatomic risk factors and subjective measures between the groups. Convergent validity was tested with a Pearson r correlation coefficient between the WARPS/STAID and ISS scores. Demographic risk factors statistically associated with a WARPS subtype included female sex, age at first dislocation and bilaterality. Pathoanatomic risk factors statistically associated with a WARPS subtype included trochlear dysplasia, TT-TG distance, generalized ligamentous laxity, patellar tilt and rotational abnormalities. The independent t test revealed a significant difference between the ISS scores: WARPS subtype (M = 4.4, SD = 1.1) and STAID subtype (M = 2.5, SD = 1.5); t(48) = 5.2, p

Context: Competency-based education requires strong planning and a vehicle to deliver and track students' progress across their undergraduate programs. Clinical presentations (CPs) are proposed as 1 method to deliver a competency-based curriculum in a Canadian undergraduate athletic therapy program.Objective: Validation of 253 CPs.Setting: Canadian universities/colleges and clinical practices.Patients or Other Participants: Six Canadian Athletic Therapists Association-accredited program directors and 6 athletic therapists with at least 10 years of experience working in both field and clinical athletic therapy settings.Intervention(s): We surveyed 12 experts who rated the importance and difficulty of 253 CPs using a 100-mm and electronic visual analog scale with extremely important at 1 anchor and irrelevant at the other end. Difficulty was measured in a similar manner anchored by extremely difficulty and extremely easy.Main Outcome Measure(s): Descriptive statistics for importance and difficulty were tabulated on all CPs. An importance-difficulty index was calculated as a mean score of both importance and difficulty scores.Results: Data were converted into quartiles to represent a 4-point categorical importance scale to mimic the original categories from the Ebel procedure (ie, essential, important, acceptable, and questionable). Difficulty was likewise converted into quartiles representing a 4-point categorical difficulty scale. Mean importance scores ranged from 99.3 for airway management (ie, most important) to 54 for high altitude cerebral edema (ie, less important). Clinical presentation difficulty scales ranged from 89.8 for biceps contusion (ie, easier) to 21.2 for decompression illness (ie, harder).Conclusions: These 253 CPs are thought to be representative (ie, valid) of the athletic therapy scope of practice in Canada. To our knowledge, CPs have not been developed in the athletic therapy context prior to this research. We anticipate more will be identified as these CPs are used to align teaching, learning, and assessment within competency-based athletic therapy programs in Canada.

Aim Patients’ experience of the quality of care received throughout their continuum of care can be used to direct quality improvement efforts in areas where they are most needed. This study aims to establish validity and reliability of the Healthcare Access and Patient Satisfaction Questionnaire (HAPSQ) – a tool that collects patients’ experience that quantifies aspect of care used to make judgments about quality from the perspective of the Alberta Quality Matrix for Health (AQMH). Background The AQMH is a framework that can be used to assess and compare the quality of care in different healthcare settings. The AQMH provides a common language, understanding, and approach to assessing quality. The HAPSQ is one tool that is able to assess quality of care according to five of six AQMH’s dimensions. Methods This was a prospective methodologic study. Between March and October 2015, a convenience sample of patients presenting with chronic full-thickness rotator cuff tears was recruited prospectively from the University of Calgary Sport Medicine Centre in Calgary, Alberta, Canada. Reliability of the HAPSQ was assessed using test–retest reliability [interclass correlation coefficient (ICC)>0.70]. Validity was assessed through content validity (patient interviews, floor and ceiling effects), criterion validity (percent agreement >70%), and construct validity (hypothesis testing). Findings Reliability testing was completed on 70 patients; validity testing occurred on 96 patients. The mean duration of symptoms was three years (SD: 5.0, range: 0.1–29). Only out-of-pocket utilization possessed an ICCA priori hypotheses were confirmed. The HAPSQ represents an inexpensive, reliable, and valid approach toward collecting clinical information across a patient’s continuum of care.

BACKGROUND Health-related quality of life measures for the adolescent patellar instability population are limited. The Banff Patella Instability Instrument (BPII) is a disease-specific health-related quality of life that has been tested on a mixed adult and adolescent population but has not been exclusively tested with an adolescent population. The purpose of this study was to determine the validity, reliability, and responsiveness of the BPII within an adolescent population. METHODS Content validation was tested with 3 measures: floor and ceiling effects; the Cronbach alpha; readability grade level. Reliability was measured with an intraclass correlation coefficient (2, k) and the SEM. Responsiveness was measured using a 1-way analysis of variance comparing preoperative BPII scores to postoperative BPII scores at 6, 12, and 24 months. Eta squared was calculated to measure effect size. RESULTS The BPII demonstrated no floor or ceiling effects. The Cronbach alpha for the BPII ranged from 0.97 to 0.98 for the preoperative and postoperative time periods. The readability index was a mean grade level of 8.9. Test-retest reliability assessment demonstrated an intraclass correlation coefficient (2, k) of 0.99 indicating strong reliability. The SEM was 1.3. There was a statistically significant difference in BPII scores for the 4 different time interval measures (F3, 176=50.04; P

Context: A published commentary from 2 of the current authors acted as a catalyst for raising some key issues that have arisen in athletic therapy education in Canada over the years. Objective: The purpose of this article is to report on the process followed to establish a number of consensus statements related to postsecondary athletic therapy education in Canada. The consensus statements should act as a future plan for entry-level athletic therapy education. Design: Content validation for consensus statements. Setting: Video-conference meetings at 7 Canadian postsecondary colleges/universities. Patients or Other Participants: Canadian Athletic Therapists' Association (CATA) program directors and CATA leaders from education, certification, and program accreditation committees. Main Outcome Measure(s): A Delphi method and modified Ebel procedure were used to gather opinions from participants about athletic therapy education. Results: We created 10 consensus statements, with a series of caveats that are presented in this article. All components received at least 80% consensus from the expert validation group. Conclusions: The final Education Task Force Report was created and content was validated by a group of experts in the topics associated with every consensus statement. The final report was presented to the CATA Board of Directors for adoption and implementation.

Context and Background Athletic therapy postsecondary education and certification requirements in Canada have reached considerable milestones throughout their history. The most important of these accomplishments was administration of the first Canadian Athletic Therapists' Association (CATA) certification examination in 1975. At that time, there were three basic exam eligibility requirements: (1) core curricular courses; (2) 1800 practical hours; and (3) a valid first aid certificate. The only significant change to these certification requirements occurred in 1976, when the 1800-hour internship requirement was reduced to 1200 hours. However, a documented rationale for this change could not be determined. The noteworthy milestone occurred when the CATA approved a policy stating that, as of September 1999, all future athletic therapy candidates would have to be enrolled in a Canadian accredited program at a postsecondary institution. Although this policy significantly advanced the CATA's postsecondary academic/curricular requirements, the 1200-hour internship requirement has remained unchanged for almost four decades. Objective The purpose of this commentary is to stimulate discussion about the linkage between the practical-hour requirements and teaching, evaluating, and achieving clinical competence. Recommendations Recommendations for change are based on lessons learned by other organizations for medical educators and allied health care professions, such as the National Athletic Trainers' Association. One suggestion for change is to hold students accountable for achieving a predetermined level of clinical competence before they move through or graduate from a program. In order to accomplish this goal, students must be assessed with valid and reliable evaluation tools. Conclusion Therefore, it is important to establish a group of stakeholders who can identify issues and articulate a plan to guide the future of postsecondary athletic therapy education in Canada.

Objective: To present a case of a rodeo cowboy who suffered a seemingly routine 1st degree acromioclavicular (AC) sprain. The AC sprain was exacerbated by an elevated 1st rib. Background: Saddle bronc riding is one of three rough stock events in North American rodeo and the least common event for injury relative to bull riding and bareback riding. Shoulder injury in rodeo rough stock events make up 9.3% of all injuries. Approximately 28% of injuries in rodeo are considered minor sprains. The professional cowboy was thrown from his horse landing on the tip of his shoulder. The cowboy presented with a routine 1st degree AC sprain based on the Tossey and Rockwood definitions. Differential Diagnosis: Due to the mechanism of injury and forces produced with the cowboy being thrown to the ground, elimination of serious neck injury was critical. A scanning examination revealed some neck dysfunction. A cervical rotation, lateral flexion special test confirmed the additional elevated 1st rib in addition to the 1st degree AC sprain. Treatment: A chiropractic adjustment of the 1st rib reduced pain in the AC joint from a 6/10 to 1/10 immediately. Subsequently, the patient iced and was treated with one other 1st rib adjustment at a later date. Uniqueness: There were no cases of 1st degree AC sprains with an associated elevated first rib in the literature. It was very unique to relieve to the patient’s shoulder symptoms so dramatically in a short period of time with manual therapy to the first rib. Conclusions: It is important to follow a thorough history and physical examination of patients who suffer from a 1st degree AC sprain. The use of a scanning examination will help identify the primary source of pain (i.e. neck and/or shoulder). Manual therapy of the 1st rib may be useful in the treatment.

Context In order to study the efficacy of assessment methods, a theoretical framework of Earl's model of assessment was introduced. Objective (1) Introduce the predictive learning assessment model (PLAM) as an application of Earl's model of learning; (2) test Earl's model of learning through the use of the Standardized Orthopedic Assessment Tool (SOAT); and (3) establish construct validity of the SOAT. Design Quasi-experimental. Setting Three Canadian universities Patients or Other Participants A convenience sample of 57 third-year undergraduate athletic therapy students from three universities were randomly assigned into three experimental groups. Intervention(s) Treatment group 1 gave the instructor access to the SOAT, but the instructor could not explicitly share it. Treatment group 2 gave both the instructor and students access to the SOAT throughout the semester to use formatively. Group three was the comparison. Main Outcome Measure(s) All students were tested using the SOAT at the end of the semester using expert raters. An analysis of variance (ANOVA) (P < .05) was used to determine whether there was a difference between groups in their final examination grades. Results The ANOVA demonstrated a significant difference between groups (F2,56 = 28.6, P < .01). The effect size, calculated using η2, was 0.51. Post hoc analysis revealed a significant difference between treatment group 2 and the other treatment group and comparison group. Conclusions Small sample size and the quasi-experimental design prevent definitive conclusions, but the SOAT was able to discriminate between various groups, supporting our construct validity objective. The SOAT was introduced as a predictive tool that may assist orthopaedic assessment skill development. The treatment group exposed to the SOAT demonstrated that formative assessment of students using the SOAT was an effective means of teaching relative to no exposure or where only the instructor was exposed to the SOAT.

Background: The Banff Patella Instability Instrument (BPII) is a disease-specific, patient-reported, quality-of-life outcome measure designed to assess patients with patellofemoral instability. The iterative assessment of the validity, reliability, and responsiveness of a health-related patient-reported outcome measure is vital to the development of a high-quality evaluation tool. Purpose: To assess the concurrent validity of the BPII to the Norwich Patellar Instability (NPI) score and the Kujala score. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 74 patients with a confirmed diagnosis of recurrent patellofemoral instability completed the BPII, NPI, and Kujala scores at the initial orthopaedic consultation. A Pearson r correlation coefficient was computed to determine the relationship between each of these patient-reported outcomes. Results: There were statistically significant correlations between the BPII and the NPI score ( r = −0.53; P < .001) as well as the BPII and the Kujala score ( r = 0.50; P < .001). Conclusion: This study demonstrated a moderately strong correlation of the BPII to other outcome measures used to evaluate patients with patellofemoral instability. This study adds further validity to the BPII in accordance with the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) guidelines.

The purpose of this study was to assess the disease-specific quality of life, and the objective clinical and functional outcomes of patients with symptomatic ACL deficiency and patellofemoral instability following surgical stabilization of both ligaments.Between February 2010 and August 2013, 22 subjects underwent a combined ACL reconstruction and patellofemoral stabilization. The anterior cruciate ligament quality of life questionnaire (ACL-QOL) was completed pre-operatively and two-years post-operatively. Clinical and functional assessments were performed two-years post-operatively. A paired t-test assessed the difference between the pre- and post-operative ACL-QOL scores. Effect size was calculated manually using the Eta squared formula. A Pearson r correlation coefficient assessed for a relationship between the post-operative ACL-QOL scores and functional tests.Twenty patients completed the 24-month ACL-QOL, 17/20 completed clinical assessment, and 14/20 completed functional testing. The mean pre-operative ACL-QOL score was 21.20 (SD=7.25, range 5.8 to 31.7) and two-years post-operative it was 65.24 (SD=21.38, range 34.5 to 99.1). The paired t-test demonstrated a statistically significant improvement in ACL-QOL scores; t (19)=9.119, p.001 (two-tailed). The Eta squared statistic (0.81) indicated a very large effect size. Statistically significant correlations (p.05) were evident between post-operative ACL-QOL scores and all the operative limb single-leg hop tests.Combined ACL reconstruction and patellofemoral stabilization surgery leads to good results. This patient cohort with chronic ACL-MPFL injuries demonstrated a statistically significant change in disease-specific quality of life following surgery. In addition, the patient-reported outcomes and objective functional testing results correlated.Case series - IV.

Background: Clinical management of patellofemoral (PF) instability is a challenge, particularly considering the number of variables that should be taken into consideration for treatment. Quality of life is an important measure to consider with this patient population. Purpose: To factor analyze and reduce the total number of items in the Banff Patella Instability Instrument (BPII). Subsequent to the factor analysis, the new, item-reduced BPII 2.0 was tested for validity, reliability, and responsiveness. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Quality of life was measured for PF instability patients (N = 223) through use of the original BPII at their initial consultation. Data from the BPII scores were used in a principal components analysis (PCA) to factor analyze and reduce the total number of items in the original BPII, to create a revised BPII 2.0. The BPII 2.0 underwent content validation (Cronbach alpha, patient interviews, and grade-level checking), construct validation (analysis of variance comparing the initial visit and the 6-, 12-, and 24-month postoperative visits, eta-square), convergent validation (Pearson r correlation to the original BPII), responsiveness testing (eta-square, anchor-based distribution testing), and reliability testing (intraclass correlation coefficient [ICC]). Results: The BPII was successfully reduced from 32 to 23 items with excellent Cronbach alpha values in the new BPII 2.0: initial visit = 0.91; 6-month postoperative visit = 0.96; 12-month postoperative visit = 0.97; and 24-month postoperative visit = 0.76. Grade-level reading for all items was assessed as below grade 12. The BPII 2.0 was able to discriminate between all time periods with significant differences between groups ( P < .05). Eta-square was 0.40, demonstrating a medium to large effect size. The BPII significantly correlated with the BPII 2.0 (0.82, 0.90, 0.90, and 0.94 at the initial visit and 6-, 12-, and 24-month postoperative visits, respectively), providing evidence of convergent validity. A significant correlation was found between the 7-point scale and 24-month postoperative BPII 2.0 scores, a sign of anchor-based responsiveness. ICC (2,k) was 0.97, indicating strong reliability. Conclusion: The BPII 2.0 is valid, reliable, and responsive for assessment of patients with PF instability, both surgically and nonsurgically treated.

The purpose of this study was to establish the content validity of the Rodeo SCAT for the sport of rodeo and bull riding. The study design was comprised of expert consensus and content validation. A modified Ebel procedure was employed to content validate the rodeo SCAT. Content validation using this method includes experts agreeing on the importance of each item that comprises the rodeo SCAT. This 3-stage process involved: 1) face validation by a local committee: 2) initial expert consensus measurement via distance; and 3) a face-to-face discussion for items that did not originally achieve 80% consensus of the group. Experts were chosen from the Canadian Professional Rodeo Sport Medicine Team (Canada) and the Justin Sports Medicine Team (USA). 27 out of a total possible 68 items achieved 80% consensus in the second stage. In the third stage, 4 of the 68 items were removed with consensus from the expert group. All remaining items achieved 80% consensus for inclusion. In summary, the rodeo SCAT is content valid and thus, appropriate for use in the sport of rodeo context or environment.

Entrapment; Mesentery; Root of the mesentery; Visceral release; Pelvic floor; Sigmoid colon; Retrovesical pouch; Perineal pain Abstract The case of a 31 year-old bareback rodeo cowboy who suffered from pelvic floor pain and spasm is presented. The clinical care pathway for this case was not simple and in fact, misdiagnosed for months prior to seeking the care of an osteopathic manual therapist. The pelvic floor muscle spasm was presumably caused by pudendal nerve entrapment even though there were no diagnostic tests such as EMG to confirm it. The entrapment was thought to be from the abdominal viscera (mesentery and sigmoid colon) being adhered to peritoneal tissue in the small pelvis. Treatment consisted of four consecutive days of osteopathic manual therapy treatment due to special patient availability and circumstances. The treat- ment focused on a release of the root of the mesentery and ischial intraosseous lesions, the release of the sigmoid colon from posterior abdominal wall and iliop- soas muscle, myofascial release of the thoraco-lumbar fascia, and myofascial release of pelvic floor musculature including balancing of three diaphragms, and harmonizing the primary respiratory mechanism within the cranial-sacral system. The etiology is thought to occur due to the sport's natural ptosis forces on the viscera. The patient returned to bareback riding without any issue and on follow- up five years later, did not report any symptoms.

Evaluation of musculoskeletal injuries requires special knowledge and skills that are shared by different health professions, but the process used to establish a diagnosis is not necessarily the same. Medicine has employed the objective structured clinical exams (OSCE) to assess clinical competence. The performances of two Canadian athletic therapists were assessed by two different methods for assessment of clinical competence in the evaluation of knee injuries. On the basis of existing standards, both of the athletic therapists would have passed the examination using the Standardized Orthopedic Assessment Tool currently used to assess the clinical competence of athletic therapy students, but both would have failed using the Academy of Sport and Exercise Medicine OSCE for sport medicine physicians. The failure could be because the performances of only two subjects were assessed, but it could also be because different constructs are represented by the two methods. If we truly want to provide patient-centered care, it should be important to have similar standards, regardless of the clinician’s professional discipline.

This study was designed to test the intra- and inter-rater reliability of the University of North Carolina's Balance Error Scoring System in 9- and 10-year-old children. Additionally, a modified version of the Balance Error Scoring System was tested to determine if it was more sensitive in this population (“raw scores”). Forty-six normally developing fourth-grade students underwent balance testing. Twelve trials measured static and dynamic balance. Four adult raters scored the balance tests to yield Cronbach's alpha scores of reliability. Intra-rater University of North Carolina Balance Error Scoring System α varied from .73 to .94 and .94 to .99 when using the raw scores. The inter-rater University of North Carolina Balance Error Scoring System α of the four raters ranged from .77 to .95 and from .88 to .98 when using the raw scores. The University of North Carolina Balance Error Scoring System shows high reliability when used with fourth-grade elementary school children; however, raw scores may show gre...

Context: Orthopaedic assessment skills are critical to the success of athletic therapists and trainers. The Standardized Orthopedic Assessment Tool (SOAT) has been content validated. Objective: To establish interrater reliability of the SOAT. Patients or Other Participants: Thirty-two college students, 10 raters, and 2 standardized patients (SPs) from Calgary, Alberta, Canada. Design: Randomized observational study. Intervention(s): Students were allowed 30 minutes to complete a mock orthopaedic assessment of an SP with an injury specific to a region of the body (shoulder, knee, or ankle). Using the region-specific SOAT, raters and SPs evaluated students' orthopaedic assessment skills. Main Outcome Measure(s): The sum totals of the SOAT for 2 raters and 1 SP were used to calculate each student's performance scores for respective scenarios. Scale reliability analysis (Cronbach α) was completed on the SOAT for each of the 3 body-region examinations. Results: The mean overall reliability of 3 SOATs (ie, ankle, knee, and shoulder) was positive: α = .85 with the SP scores factored into the equation and α = .86 without the SP scores factored into the equation. Reliability for the ankle region was highest (α = .91), followed by the knee (α = .83) and the shoulder (α = .82). Conclusions: The study sample size was small, but the results will enable further study with generalization to a broader audience of athletic therapists and athletic trainers. Because a baseline measure of reliability was established using a robust statistical analysis, future researchers can employ more stringent statistical analysis and focus on the effects of various pedagogical techniques to teach and learn the underlying construct of clinical competence in orthopaedic assessment.

The purpose is to provide more validity, reliability, and responsiveness testing of the anterior cruciate ligament-quality of life instrument (ACL-QOL), particularly in light of consensus-based standards for the selection of health status measurement instruments (COSMIN) guidelines.Prospective case series.An orthopedic surgical practice for consultation.A convenience sample of 579 ACL-deficient patients.Anterior cruciate ligament reconstructive surgery.Patients completed the ACL-QOL at initial visit and underwent reconstructive surgery. Patients were followed at 6, 12, and 24 months using the ACL-QOL to determine its validity and responsiveness. Cronbach's alpha was used to determine the unidimensionality of the ACL-QOL. A subset of patients took the ACL-QOL twice in a test-retest reliability analysis (intraclass correlation coefficient or ICC 2,k). Another subset of 24-month postsurgical patients measured the success of their surgery using a 7-point global rating scale of improvement as an anchor-based method of responsiveness.Cronbach's alpha coefficients = 0.93, 0.95, 0.96, and 0.98 at 6, 12, and 24 months, respectively. Intraclass correlation coefficient = 0.60, SEM = 6.16, and confidence interval of 12.1 (CI 95%). Responsiveness was measured by comparing the 4 serial time periods. Patients improved significantly at each time period (P0.05, ETA squared 0.61). A 24-month ACL-QOL was significantly correlated (P0.05) to being "significantly better" or "somewhat better."The results of this study added more validity, reliability, and responsiveness for the ACL-QOL. The ACL-QOL has completed 8 of 9 COSMIN criteria.

Content validation of an instrument that measures student performance in OSCE-type practical examinations is a critical step in a tool's overall validity and reliability [Hopkins (1998), Educational and Psychological Measurement and Evaluation (8th ed.). Toronto: Allyn & Bacon]. The purpose of the paper is to outline the process employed to create a content-valid Standardized Orthopedic Assessment Tool (SOAT). Orthopedic assessment skills are employed by athletic therapists, physiotherapists and physicians. All follow very similar diagnostic algorithms and that system was used to develop the original SOAT [Cyriax (1982). Textbook of Orthopaedic Medicine, (vol. 1) Bailliere Tindall]. To validate the tool, the study followed procedures outlined by Violato, Salami, and Muiznieks (2002), Journal of Manipulative Physiological Therapeutics, 25, 111–115, and Butterwick, Paskevich, Vallevand and Lafave (2006), Journal of Allied Health: a modified Ebel procedure. An expert group of athletic therapists from across Canada were chosen to create the content valid tool. Representation from all accredited athletic therapy programs in Canada was sought. Experts participated in three stages of content validation: Stage one consisted of individuals grading tasks on difficulty (hard, medium, easy) and importance (essential, important, not important) for 8 body regions (cervical spine, lumbar spine, shoulder, elbow, wrist/hand/thumb, hip, knee and lower leg/foot/ankle) and three diagnoses for each body region (24 total). If 80% consensus was not achieved in the first stage, then in stage two, face to face discussion is meant to clarify positions and achieved consensus, if possible. The history component, the observation component, scanning exams, clearing joints above and below the lesion site and active range of motion, passive range of motion and isometric resisted testing all yielded 80% consensus in the first two stages of development. A third stage was added to this process because a new model of measurement was conceptualized during the second stage due to a lack of consensus on two orthopedic assessment categories: special testing and palpation. The new model consisted of a ``clinical reasoning" metric that tied each section of an orthopedic assessment (history; observation; scanning and clearing; examination, special testing; palpation; conclusion) together and would permit the expert rater to evaluate the student performance based on the student's rationale for tests chosen rather than the traditionally rigid checklists. At least 80% consensus was achieved with the new ``clinical reasoning" metric and the originally contentious special testing and palpation categories. The new SOAT that underwent content validation may be a hybrid between the traditional OSCE-type checklists and global scales that provide a more realistic and thus more valid depiction of orthopedic assessment clinical competence. Now that content validation has been established, the next steps include inter-rater reliability testing.

Utilization of conceptual models in field-based emergency care currently borrows from existing standards of medical and paramedical professions. The purpose of this study was to develop and validate a comprehensive conceptual model that could account for injuries ranging from nonurgent to catastrophic events including events that do not follow traditional medical or prehospital care protocols. The conceptual model should represent the continuum of care from the time of initial injury spanning to an athlete’s return to participation in their sport. Finally, the conceptual model should accommodate both novices and experts in the AT profession. This paper chronicles the content validation steps of the Continuum of Care Conceptual Model for Athletic Therapy (CCCM-AT). The stages of model development were domain and item generation, content expert validation using a three-stage modified Ebel procedure, and pilot testing. Only the final stage of the modified Ebel procedure reached a priori 80% consensus on three domains of interest: (1) heading descriptors; (2) the order of the model; (3) the conceptual model as a whole. Future research is required to test the use of the CCCM-AT in order to understand its efficacy in teaching and practice within the AT discipline.

Background: Medial patellofemoral ligament (MPFL) reconstruction is a procedure aimed to reestablish the checkrein to lateral patellar translation in patients with symptomatic patellofemoral instability. Correct femoral tunnel position is thought to be crucial to successful MPFL reconstruction, but the accuracy of this statement in terms of patient outcomes has not been tested. Purpose: To assess the accuracy of femoral tunnel placement in an MPFL reconstruction cohort and to determine the correlation between tunnel accuracy and a validated disease-specific, patient-reported quality-of-life outcome measure. Study Design: Case series; Level of evidence, 4. Methods: Between June 2008 and February 2014, a total of 206 subjects underwent an MPFL reconstruction. Lateral radiographs were measured to determine the accuracy of the femoral tunnel by measuring the distance from the center of the femoral tunnel to the Schöttle point. Banff Patella Instability Instrument (BPII) scores were collected a mean 24 months postoperatively. Results: A total of 155 (79.5%) subjects had adequate postoperative lateral radiographs and complete BPII scores. The mean duration of follow-up (±SD) was 24.4 ± 8.2 months (range, 12-74 months). Measurement from the center of the femoral tunnel to the Schöttle point resulted in 143 (92.3%) tunnels being categorized as “good” or “ideal.” There were 8 failures in the cohort, none of which occurred in malpositioned tunnels. The mean distance from the center of the MPFL tunnel to the center of the Schöttle point was 5.9 ± 4.2 mm (range, 0.5-25.9 mm). The mean postoperative BPII score was 65.2 ± 22.5 (range, 9.2-100). Pearson r correlation demonstrated no statistically significant relationship between accuracy of femoral tunnel position and BPII score ( r = –0.08; 95% CI, –0.24 to 0.08). Conclusion: There was no evidence of a correlation between the accuracy of MPFL reconstruction femoral tunnel in relation to the Schöttle point and disease-specific quality-of-life scores. Graft failure was not related to femoral tunnel placement. The patellofemoral instability population is complex, and patients present with multiple risk factors that, in addition to the accuracy of femoral tunnel position, contribute to quality of life and warrant further investigation.

Context: Health care professions have replaced traditional multiple choice tests or essays with structured and practical, performance-based examinations with the hope of eliminating rater bias and measuring clinical competence. Objective: To establish the validity and reliability of the Standardized Orthopedic Assessment Tool (SOAT) as a measure of clinical competence of orthopaedic injury evaluation. Design: Descriptive laboratory study. Setting: University. Patients or Other Participants: A total of 60 undergraduate students and 11 raters from 3 Canadian universities and 1 standardized patient. Intervention(s): Students were required to complete a 30-minute musculoskeletal evaluation in 1 of 2 randomly assigned mock scenarios involving the knee (second-degree medial collateral ligament sprain) or the shoulder (third-degree supraspinatus muscle strain). Main Outcome Measure(s): We measured interreliability with an intraclass correlation coefficient (ICC) (2,k) and stability of the tool with standard error of measurement and confidence intervals. Agreement was measured using Bland-Altman plots. Concurrent validity was measured using a Pearson product moment correlation coefficient whereby the raters' global rating of a student was matched to the cumulative mean grade score. Results: The ICCs were 0.75 and 0.82 for the shoulder and knee cases, respectively. Bland-Altman plots indicated no systematic bias between raters. In addition, Pearson product moment correlation analysis demonstrated a strong relationship between the overall cumulative mean grade score and the global rating score of the examinees' performances. Conclusions: This study demonstrated good interrater reliability of the SOAT with a standard error of measurement that indicated very modest stability, strong agreement between raters, and correlation indicative of concurrent validity.

Context: Athletic taping skills are highly valued clinical competencies in the athletic therapy and training profession. The Technical Skill Assessment Instrument (TSAI) has been content validated and tested for intrarater reliability. Objective: To test the reliability of the TSAI using a more robust measure of reliability, generalizability theory, and to hypothetically and mathematically project the optimal number of raters and scenarios to reliably measure athletic taping skills in the future. Setting: Mount Royal University. Design: Observational study. Patients or Other Participants: A total of 29 university students (8 men, 21 women; age = 20.79 ± 1.59 years) from the Athletic Therapy Program at Mount Royal University. Intervention(s): Participants were allowed 10 minutes per scenario to complete prophylactic taping for a standardized patient presenting with (1) a 4-week-old second-degree ankle sprain and (2) a thumb that had been hyperextended. Two raters judged student performance using the TSAI. Main Outcome Measure(s): Generalizability coefficients were calculated using variance scores for raters, participants, and scenarios. A decision study was calculated to project the optimal number of raters and scenarios to achieve acceptable levels of reliability. Generalizability coefficients were interpreted the same as other reliability coefficients, with 0 indicating no reliability and 1.0 indicating perfect reliability. Results: The result of our study design (2 raters, 1 standardized patient, 2 scenarios) was a generalizability coefficient of 0.67. Decision study projects indicated that 4 scenarios were necessary to reliably measure athletic taping skills. Conclusions: We found moderate reliability coefficients. Researchers should include more scenarios to reliably measure athletic taping skills. They should also focus on the development of evidence-based practice guidelines and standards of athletic taping and should test those standards using a psychometrically sound instrument, such as the TSAI.

OBJECTIVES: To document injury rates and treatment use during one competitive season of Canadian professional rodeo. DESIGN: Prospective cohort study. SETTING: Canadian professional rodeo competition. SUBJECTS: Competitors, included professional cowboys from Australia, Brazil, New Zealand, the United States, and Canada. METHODS: Data were gathered prospectively at 15 of 68 professional rodeos in Canada, constituting 22% of all Canadian professional rodeos. Data were collected by four certified athletic therapists using a standardized form. MAIN RESULTS: Overall, 94 athletes were injured during 3,882 individual competitor exposures (CEs). The composite injury rate was 2.3 per 100 CEs. This rate is lower than that reported in contact sports. Within the context of rodeo injuries, bareback riders and bull riders had similar high injury rates (4.6 and 3.6 per 100 CEs, respectively). Saddle bronc riders and steer wrestlers had moderate injury rates (1.4 and 0.9 per 100 CEs, respectively), whereas calf ropers had low injury rates (0.5 per 100 CEs). The knee and ankle were the most frequently treated sites of the body, followed by the shoulder, elbow, and lower back. Acute injury care and prophylactic taping were the most frequent services provided. CONCLUSIONS: In order to study injury patterns in more detail and to assess risk factors for injury, a larger scale epidemiological study should be undertaken. Through such risk-based analysis, preventative strategies could be identified. Language: en