SCREEN first for competency and risk to tell you whether you need to do more ASSESSMENT for causes/contributing factors/complicating factors, ie regress, or to proceed to TEST capacity, ie progress.
Any of these could be used in Pre-Participation Evaluations (PPE's).
Choose a screen, assessment battery or test battery that reveals the ability to respond, then adapt to external and internal stimuli. Recognise that the heirarchy of evaluation is:
1) below bodyweight
2) at bodyweight
3) above bodyweight
Assessments should reveal either the cause/contributing factor or complicating factor to why the person is rated as below competence or at below minimum capacity. A test that follows from a competent assessment and screen should also reveal cause/contributing factor or complicating factor to why the person is rated as below competence or at below minimum capacity.
Recommendations made in this learning module honour the above. Those evaluations that do not clearly honour the above are not recommended.
There are three areas to evaluate pre-participation.
Health systems of the human.
Function as it relates to movement competency as a human, not as a human within a sport.
Performance as it relates to fundamental human movement capacity.
Performance as it relates to sports-specific movement capacity.
Evaluations should reveal competency and capacity separately to avoid confusion as to what is the limiting factor in a persons capacity. For example, an individual who has movement competency issues and is then tested for capacity will most likely demonstrate reduced capacity - to the less focussed assessor, the deficits may be blamed on reduced capacity, directing interventions there, failing to recognise that reduced competency affects expression of capacity. Some evaluations combine competency and capacity in one test, a flaw in testing. For example, consider an individual who is tested for single hop for distance but who has an underlying ankle dorsiflexion limitation, below competent. This individual is less likely to express sufficient force production to hop a minimum acceptable distance, and/or is less likely to express sufficient dynamic motor control and/or force absorption to land with competence. A reduced hop distance, below minimum acceptable, might be seen as a capacity problem if the underlying mobility or motor control problems in the lower quarter and trunk were NOT first revealed with a competency screen.
Recommendations made in this mindmap are held against four criteria:
1. Is the evaluation reliable?
2. Is there some evidence of validity of the findings from the evaluation?
3. Is the evaluation sensitive to change?
4. Is it portable and easy to administer once trained?
Evaluations that go some way towards addressing the above criteria are given preference in recommendation.
A pre-participation evaluation should be reliable between sessions and between individual evaluators. This provides objectivity and improves communication between testers.
Any exisiting pre-participation evaluation should be scrutinised for the presence or absence of reliability studies.
The degree to which a test measures what it claims, or purports, to be measuring.
For example, a pre-participation evaluation is typically looking "for signs or symptoms of underlying disease, or who may be at higher risk of an adverse event during exercise" (Essa, 2018)
The presence of increased risk in a screen should lead to further assessment. See individual injury discussions within this module for risks and predisposing factors for ACL, patellofemoral pain, shoulder tendinopathy and lateral ankle injury.
ESSA, 2018. https://www.essa.org.au/for-gps/adult-pre-exercise-screening-system/
Criterion or concrete validity is the extent to which a measure is related to an outcome. Criterion validity is often divided into concurrent and predictive validity.
Concurrent validity refers to a comparison between the measure in question and an outcome assessed at the same time.
Predictive validity, on the other hand, compares the measure in question with an outcome assessed at a later time.
Concerns have been raised whether the variable ACL return-to-sport criteria utilized in current clinical practice are stringent enough to achieve safe and successful return-to-sport. For example, strength and hop tests have been shown to overestimate knee function after ACL injury. This is an example of the measure in question (limb symmetry index cut points in strength and hop tests) NOT being comparable in importance to estimated pre-injury capacity. Applying limb-symmetry index's of 90%, which is common in clinical practice, is an example of poor criterion validity.
Wellsandt, E., Failla, M. J., & Snyder-Mackler, L. (2017). Limb Symmetry Indexes Can Overestimate Knee Function After Anterior Cruciate Ligament Injury. J Orthop Sports Phys Ther, 1-18. doi:10.2519/jospt.2017.7285 http://www.ncbi.nlm.nih.gov/pubmed/28355978
Content validity (also known as logical validity) refers to the extent to which a measure represents all facets of a given construct.
For example, a pre-participation evaluation may lack content validity if it only assesses the range of motion and strength of an individual, ie the part specific competence and capacity, but fails to take into account the behavioral dimension, or pattern-specific competence and capacity.
Further, a pre-participation evaluation may lack content validity if it does not evaluate seemingly unrelated elements. For example, the essence of regional interdependence is that pain or movement-below-competence anywhere can affect a movement pattern in the whole kinetic chain.
Regional interdependence: Wainner, R. S., Whitman, J. M., Cleland, J. A., & Flynn, T. W. (2007). Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther, 37(11), 658-660. doi:10.2519/jospt.2007.0110 https://www.ncbi.nlm.nih.gov/pubmed/18057674
Modifiable and sensitive to change
A measure used in a pre-participation evaluation should be modifiable. For example, a pre-participation evaluation which only includes the presence or not of previous injury is one that is revealing that which is not modifiable. A PPE should include indicators, with criteria, of modifiable risk factors. The PPE itself should be able to detect when changes to those risk factors have occurred, ie the scale of measurement should reflect significant change, for better or worse.
Easily administered once trained, and portable
All PPE's require technical instruction for testers, with reflective practice. The purpose is to bring all testers up to not miss important information. This reduces false negatives. It also ensures individuals are directed onwards for higher level testing when they pass minimum levels of competency, ie normal risk. It also ensures individuals are directed appropriately for further assessment when they do not pass minimum levels of competency. For example, an individual who's resting blood pressure is 150/110 has undergone a reliable test, with construct validity of a measure that is modifiable, sensitive to change, using an easily administered test that is portable, and which directs the person to be further assessed as to what might be causing, contributing or complicating normal blood pressure.
In PPE's that relate to risk factors for ACL injury, there exist baseline screens and assessments that can be taught, easily administered in small time periods, require minimal equipment that is portable and that can be reliable, valid for risk factors, capture modifiable risks and are sensitive to change.
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