












































PATIENT-CENTERED CARE COMMENTARY 

14 
   Clinical Practice in Athletic Training 
  Volume 1 – Issue 2 – October 2018 

Guidelines for Useful Integration of Patient-Rated Outcome 
Measures into Clinical Practice 
Skye Livermore-Brasher, MPA, AT1; Russell Baker, PhD, DAT, MS, AT1; Alan Nasypany, Ed.D., M.Ed., AT1; 
and Scott Cheatham, Ph.D., DPT, LPT, ATC2 

1The University of Idaho, Moscow, ID; 2California State University Dominguez Hills, Carson, CA 

Key Phrases 
Patient-reported outcomes, patient education, policy and 
procedure development 

Correspondence 
Skye Livermore-Brasher, University of Idaho, 407 Lumpkin 
St., Fort Benning, GA 301905. 
E-mail: skyelivermore123@hotmail.com

Full Citation 
Livermore-Brasher S, Baker R, Nasypany A, Cheatham S. 
Guidelines to Useful Integration of Patient-Rated Outcome 
Measures into Clinical Practice. Clin Pract Athl Train. 
2018;1(2):14-30. 
https://doi.org/10.31622/2018/0002.4 

Submitted: July 24, 2018  Accepted: October 17, 2018 

COMMENTARY 

Outcome measures gauge intervention 
effectiveness in an evidence-based, patient-
centered practice. Patient-rated outcomes (PROs) 
are tools to measure the perceived effectiveness 
of a clinician’s practice, while serving as 
instruments to improve clinician-patient 
communication and health-related quality of life 
(HRQoL).1,2,3 While clinicians may recognize the 
importance of PRO usage in practice, adoption 
into practice can be perceived to be burdensome. 
In one study, only 26% of the sample of athletic 
trainers used PRO measures regularly in practice.4 
The assortment, variation, and abundance of 
available measures can be defeating to a 
clinician who is a novice at utilizing PROs. 
Clinicians may lack knowledge regarding PRO 
usage and interpretation, and may struggle with 
developing the habit of using the instruments in 
practice. Furthermore, they may lack an 
understanding of how to interpret PROs for their 
unique patient populations. The purpose of this 
paper is to introduce and discuss valid PROs that 
can be used easily across most athletic training 
patient populations, and to present a model to  

Copyright © by Indiana State University      
All rights reserved. ISSN Online 2577-8188 

begin implementing the use of these PROs in 
practice.   

PATIENT-CENTERED CARE 

Outcome measures are an essential part of whole-
person care, “comprehensive care that considers 
and addresses all aspects of disability, from the 
impairment of body structures and functions to 
activity limitations and participation restrictions.”4 
Outcome measure collection is a crucial aspect of 
patient-centered care for several reasons. First, 
for individual patients, using outcome measures 
provides means for patient-clinician 
communication about HRQoL factors beyond 
primary complaint, such as social and economic 
well-being.1 Clinicians may become aware of 
information about symptoms not discussed during 
the history, symptoms whose severity was 
downplayed, or symptoms which are difficult to 
discuss.3 Secondly, outcome measure collection can 
be used to investigate the effectiveness and 
efficacy of clinical care by individual healthcare 
practitioners, clinics, programs, or hospitals, and 
particular treatments and interventions.1 Finally, 
outcome measure collection improves quality,1 
evaluating and making changes in clinical care,1 
and determining the effects of translational 
research into practice.5 

While athletic training clinicians are already 
adept at gathering clinician-oriented outcome 
measures such as range of motion and manual 
muscle testing, researchers and educators urge 
clinicians to begin collecting PRO measures.4 
Generic patient-rated outcome measures address 
a broad range of health concepts, focus on 
HRQoL, and cover a wide variety of health 
domains.6 Patient-rated outcomes can also be 
specific measures, such as region-specific (ankle, 
shoulder), disease specific (migraines, asthma), or 

https://doi.org/10.31622/2018/0002.1


Guidelines for Useful Integration of Patient-Rated Outcome Measures into Clinical Practice 

15 
Copyright © by Indiana State University         Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188   Volume 1 – Issue 2 – October 2018  

dimension-specific (pain, fear avoidance) 
instruments.6 Patient-rated outcomes provide the 
patient perspective and a valuable indication of 
the effects of the patient’s condition on HRQoL.4 
Benefits to PRO use include providing information 
central to patient-oriented evidence that matters 
(POEM), advancing the athletic training 
profession, and enabling evidence-based athletic 
training practice.6 Patients’ perceptions of 
improvement or perceived degree of change may 
exert an important influence on reports of 
satisfaction of care.7 Clinicians may use data 
generated by PRO measures along with clinician-
rated measures such as range of motion and 
strength tests as part of an overall clinical 
outcomes management plan to assess their clinical 
care and improve their athletic training 
practice.2,6,8 These benefits support the immediate 
adoption of PROs into clinical use.  

The general population of athletic trainers, 
however, has thus far failed to adopt PROs in 
practice. Valier et al. reported that 74% (n=311) 
of athletic trainers who completed a survey about 
PRO use in practice (n=421) indicated they did 
not use PRO measures.4 This finding is similar to 
trends in other rehabilitation professions. Nicholas 
et al. reported that 52% of clinicians failed to 
record standardized outcome measures at 
discharge during a 12-month mandatory 
reporting period.9 Barriers identified in the 
implementation and use of PROs include confusing 
to the patient, time-consuming for the clinician, and 
lack of clinician knowledge.9 The large variety 
and different classifications of PROs is one reason 
why PRO use is burdensome to clinicians in routine 
practice.6  

EVALUATING THE UTILITY OF A PATIENT-
RATED OUTCOME MEASURE  

Two elements of a PRO to consider before 
implementing a specific measure in practice are 
essential elements and clinical utility.8 Essential 
elements involve psychometric measures of the 
soundness of the instrument and its development.8 
Psychometrics and clinimetrics are the 
methodologies used to develop and evaluate 
instruments such as PROs (Table 1).10 These 

methodologies are evaluated for a PRO for a 
wide range of conditions, because the instrument 
may respond differently in varying populations 
with varying severity. Two important types of 
validity are content validity, the extent items in 
the instrument assess the same content, and 
construct validity, how well the instrument 
measures a theoretical construct.9 Reliability is a 
measure of consistency under repetition of 
constant conditions.11-13 Responsiveness is a 
measure of how well the instrument measures 
change over time.12,13 Clinical utility involves the 
acceptability, feasibility, and appropriateness of 
using the PRO in clinical practice.8 The clinician 
must determine if the instrument is useful, time- 
and cost-effective, and acceptable to both 
himself and the patient.8 Clinicians use the 
minimal clinically important difference (MCID) to 
measure change. The MCID is a threshold value 
for change that a patient considers worthwhile 
and meaningful.14 For example, the MCID for the 
numeric pain rating scale (NRS) is generally 
considered to be 2 points on a scale from 0 (no 
pain) to 10 (worst imaginable pain). Once a PRO 
has been selected that meets both the essential 
elements and the clinical utility, the 
implementation into practice becomes easier.  

GENERIC PATIENT-RATED OUTCOME 
MEASURES  

When clinicians decide to incorporate PROs into 
practice, setbacks may arise in difficulty choosing 
which measures to use. The sheer number of 
available instruments may leave the clinician 
feeling overwhelmed before beginning. A good 
starting place for the novice PRO user is generic 
measures because they are designed to be 
appropriate to a wide range of patients.18 
Generic patient-rated outcome measures are 
defined as “scales intended to measure a broad 
range of health status facets.”6 Benefits to generic 
PROs include applicability to a wide range of 
patients, ability to compare across groups, and 
the establishment of normative values within 
practice.6 Generic PROs provide the athletic 
trainer information about both individual patient  



PATIENT-CENTERED CARE COMMENTARY 

16 
Copyright © by Indiana State University         Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188   Volume 1 – Issue 2 – October 2018 

Table 1. Psychometric Measures in Patient-Rated Outcome Scales 
Psychometric 
Measure 

Definition 

Validity The soundness or correctness of an 
instrument in measuring what it is 
designed to measure8,10,11,15-18 

Does it measure what it is 
supposed to measure? 

Must be established for each target 
population8 
Correlation Coefficient Values:19 
-1.0:  Perfectly negative correlation
-0.8:  Strongly negative correlation
-0.5:  Moderately negative correlation
-0.2:  Weakly negative correlation
0.0:  No association
+0.2:  Weakly positive correlation
+0.5:  Moderately positive correlation
+0.8:  Strongly positive correlation
+1.0:  Perfectly positive correlation

Content Validity The extent to which the items on a 
measure assess the same content, 
or how well the content material 
was sampled8,10, 18,20,21 
Do experts/patients think it 
measures what it is intended to 
measure?   
Has it been tested on a large 
enough sample population?  

May be evaluated by expert panel and/or 
patients8,10 

Criterion Validity The extent to which a statistically 
significant relationship exists 
between the measure and a 
criterion15,18 
Does it correspond with a “gold 
standard” measure?  

Gold standards are difficult to find for PROs 
because there is wide variation8,10 
Often evaluated in comparison with other PROs 
or clinical data22 

Construct Validity The extent to which a measure 
evaluates the theoretical construct 
or trait8,10,17,18,20 
If it is intended to measure a 
particular construct (e.g. pain, 
function), is that what it measures? 

Must be established for each population8 

Reliability The measure of consistency of 
date when measurements are 
taken more than once under the 
same conditions8,15, 17,18,20  
If nothing has changed in the 
patient’s condition, is the score the 
same from one point to another? 

Establishes that changes observed are due to 
intervention and not problems with the 
instrument18 
Reliability Ranges:23 
     0.00-0.10:  Virtually no reliability 
     0.11-0.40:  Slight reliability 
     0.41-0.60:  Fair reliability 
     0.61-0.80:  Moderate reliability 
     0.81-1.0:    Substantial reliability 

Test-Retest 
Reliability 

The reliability of a patient’s 
response when the instrument is 
administered multiple times24 
If a patient’s health status does 
not change, will the answers 
remain the same? 

Reflects patient’s condition rather than 
instrument error8,18,24 



Guidelines for Useful Integration of Patient-Rated Outcome Measures into Clinical Practice 

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Copyright © by Indiana State University         Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188   Volume 1 – Issue 2 – October 2018  

Table 1. Psychometric Measures in Patient-Rated Outcome Scales (Continued) 
Internal 
Consistency 

The reliability of the items within 
the scale8,18,24 
Do all items in the instrument 
measure the same health domain? 

Homogeneity of the questions related to a 
specific health domain8 

Responsiveness The instrument’s ability to detect 
change over time7,15,16,20, 21,25 
Does it measure change?  If no 
change occurs, does it remain 
static? 

Instrument must detect changes over time that 
matter to patients18 

Can be measured statistically or clinically8 

Standard Error of 
Measurement 
(SEM) 

The variation in score due to error 
rather than true observed 
change8, 11,14 
How much change is due to error? 

Point values associated with scale8 

Minimal 
Detectable 
Change (MDC) 

The smallest change that can be 
measured above that which would 
occur due to error8,11,20,26,27 
How much change is due to 
genuine change? 

Point values associated with scale8 

Minimal Clinically 
Important Change 
(MCID) 

A threshold value representing 
change that is considered 
meaningful and worthwhile by the 
patient8,14,20,24,28,29 
What amount of change is 
meaningful to the patient? 

Point values associated with scale8 
Important because clinical measures of 
improvement are not necessarily meaningful to 
patients, or may not correspond to patients’ 
perception of improvement or deterioration14 

care and overall practice trends.8 Disadvantages 
include information without sufficient detail to 
assess specific patient condition, lack of 
relevancy to some conditions, and less sensitivity 
to change from an intervention than specific 
scales.6 Commonly used generic PROs are the 
Short-form Health Survey, Sickness Impact 
Profile, Child Health Questionnaire, and 
Pediatrics Outcomes Data Collection Instrument.6  

Several PROs are applicable in the athletic 
training setting. The numeric pain rating scale 
(NRS) is commonly collected during history intake 
in practice, and can be used as a PRO.30 The 
global rating of change (GRoC) is another easy-
to-implement scale that can be adopted into 
practice.22,31 Further, two generic scales may be 
useful in athletic training because they were 
designed for physically active populations 
experiencing musculoskeletal injuries: the Patient-
Specific Functional Scale (PSFS)32 and the 
Disablement in the Physically Active scale 
(DPAS).24 These generic PRO measures may be 

used individually or in conjunction to increase the 
clinician’s understanding of the patient’s functional 
status, disablement, and HRQoL. 

FOUR GENERIC PATIENT-RATED OUTCOME 
MEASURES TO CONSIDER IN PRACTICE:  

Numeric Pain Rating Scale (Table 2) 

Pain is one of the primary reasons patients seek 
medical attention.15,30 Each patient presents with 
a different pain experience that is complete and 
multidimensional,15 and the clinician cannot 
compare the meaning of one person’s pain to 
another.33 The NRS can be used to compare the 
intensity of pain from one time point to another. 
The NRS is an 11-point scale with no pain as its 
lower anchor (0) and worst pain imaginable as its 
upper anchor (10).15,17,30,33-43 The numeric values 
lack word assignment, allowing each patient to 
assign importance at each level based on life 
experience and interpretation.33 The clinician can 
establish a time frame when asking the patient to 



Guidelines for Useful Integration of Patient-Rated Outcome Measures into Clinical Practice 

18 
Copyright © by Indiana State University         Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188   Volume 1 – Issue 2 – October 2018  

rate pain, such as best, worst, current, at onset, on 
average, during the last 24 hours, on average  
during the past 2 days, etc.15,30,33 A reduction of 
score by any patient indicates improvement.33 In  
athletic training practice, the NRS may be used to 
evaluate immediate changes in the patient’s pain 
from before to after intervention as well as over  
the duration of care for a particular injury or 
illness.  

Global Rating of Change Scale (Table 3, 
Appendix 122) 

Health-related quality of life (HRQoL) may be 
difficult to measure as a multifaceted construct. 
The GRoC is a quick and simple scale used to 
measure self-perceived change in HQoL.31 Unlike 
other outcome measures which are designed to 
evaluate a specific dimension of health such as  

Table 2:  Psychometrics for Numeric Pain Rating Scale (NPRS). 
PURPOSE Measure perceived intensity of pain15,30,36,37 
GENERAL DESCRIPTION 11-point interval scale ranging from no pain to worst

pain imaginable15,17,30,36,38

METHOD OF COLLECTION Verbal38 
TEST-RETEST RELIABILITY  
(Intraclass correlation coefficient 2,1) 

Fair reliability:  
     0.5944  
Moderate reliability:   
0.63 for last 24 hours, 0.70 for 2-day average 35 
0.63, CI95%:0.28-0.8645 
0.7417 
Substantial reliability:   
 0.9225 

VALIDITY 
(Spearman’s R) 

0.74, p<0.001: High validity34 
(Strong positive correlation) 

SEM 1.07 (90%CI)17 
0.86 (95%CI)25 
1.5 (95% CI: 1.3-1.6) 24 hours; 1.3 (95% CI: 1.1-1.4) 
2 day35 
1.7 (unchanged condition), 1.8 (minimum change in 
condition)44 
1.453 Back and buttock, 1.58 Thigh and leg 46 

MDC 2.517 
2.425 
3.5 (31%) 24 hours; 3.0 (27.3%) 2 day35 
4.144 
3.69 Thigh and leg, 3.39 Back and buttock46 

Minimum Clinically Important Difference 
Low Back Pain 4.025 

2.041 
1.047 

Shoulder Pain 1.117 
2.239 

Patellofemoral Pain 1.240 
Acute Pain 1.337 

1.438 
Fibromyalsia Pain 2.143 
Cervical Radiculopathy 2.244 

Average MCID (from these studies) is 1.5 
MCID for clinical use (based on these studies): 2.0 



Guidelines for Useful Integration of Patient-Rated Outcome Measures into Clinical Practice 

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Copyright © by Indiana State University         Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188   Volume 1 – Issue 2 – October 2018  

pain or function, the GRoC allows patients to 
provide a global rating of their overall health 
status by choosing what is most important to 
them.22 The GRoC consists of a single question 
requesting the patients to assess their change on 
a designated scale from a previous time point to 
the current time point.13,14,48,49 Various numeric 
scales (i.e., 7-, 11-, and 15-point scales) have 
been used in research.31   Based on clinometric 
properties, there isn’t a difference in 
responsiveness among the different point scales; 
however, the 11-point scale may be easiest to use 
in clinical practice because it aligns with the 11-
point NRS and has similar values (e.g. MDC and 
MCID) to the NRS.22 There are indications that 
recall bias, i.e. inability to recall the initial status 
after a period, affects the accuracy of the GRoC. 
13,14,48,49 The GRoC can be meaningful in the 
athletic training setting when used in conjunction 
with other generic and regional PROs 

Patient-Specific Functional Scale (Table 4, 
Appendix 232) 

Stratford et al.32 developed the PSFS in 1995 to 
provide a resolution to the following problems 
they observed in the implementation of PROs in 
orthopedic practice. First, clinicians’ caseloads 
were too varied to support the use of any one, 
two, or multiple questionnaires.33 Secondly, 
traditional health status measures lacked 
adeptness at providing valid assessment for 

patients functioning at a high level of 
independence.32 Finally, available measures of 
improvement did not necessarily emphasize the 
patient’s concept of improvement over that of 
clinician perceived improvement.32  The PSFS is a 
self-reported, patient-specific measure designed  
to assess functional change primarily for patients 
suffering from musculoskeletal disorders.20  

The format of the PSFS is simple and easy to 
administer. Patients identify 3-5 important 
activities that they are unable to perform or with 
which they are having difficulty due to their 
injury.32 Each activity is rated from 0-10 
regarding the current level of difficulty, with the 
lower anchor (0) indicating that the patient is 
“unable to perform activity” and the upper anchor 
(10) indicating an ability “to perform activity at
pre-injury level.”32 The PSFS is administered
before intervention occurs to maximize focus on
functional activity instead of impairment.51 Post-
intervention, the PSFS may be re-administered,
and the identified activities may be used
throughout the treatment duration to assess
change.33 However, the patient may nominate
new activities that arise when completing the PSFS
during follow-up visits.32 The structure of the PSFS
renders it extremely adaptable to the patient’s

Table 3:  Psychometrics for Global Rating of Change (GROC) Scale 
PURPOSE Measure overall health status based on what is important to 

the patient22,31 
GENERAL DESCRIPTION Recall-based questionnaire of well-being based on 

progress since initial treatment encounter22,48 
15-point scale ranging from “a very great deal worse” (-7)
to “a very great deal better” (+7)22,48

*May also use 11-point scale (-5 to +5)22

ANTICIPATED TEST LENGTH Seconds 
NUMBER OF ITEMS One item22,31,48 
METHOD OF COLLECTION Verbal,22 paper,22 electronic 
TEST-RETEST RELIABILITY  
(Intraclass correlation coefficient 2,1) 

Substantial reliability:  
     0.90, CI95%:0.84-0.93 for 11-point scale16 

VALIDITY  
(Spearman’s correlation) 

0.72, p<.05 for 15-point scale16 
0.87 for 7-point scale50 
(Strong positive correlation) 

SEM None reported 
MDC .45 on 11-point scale22 

Minimum Clinically Important Difference 
MCID for clinical use:  222 



Guidelines for Useful Integration of Patient-Rated Outcome Measures into Clinical Practice 

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Copyright © by Indiana State University         Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188   Volume 1 – Issue 2 – October 2018  

Table 4:  Psychometrics for Patient Specific Functional Scale (PSFS). 
PURPOSE Determine functional activities most important to an individual 

patient with associated rating of difficulty20,52-55  
GENERAL DESCRIPTION 11-point interval scale rating patient-specified functional activities

from 0 (unable to perform activity) to 10 (can perform fully)32,52-54

ANTICIPATED TEST LENGTH 2-6 minutes51,55

NUMBER OF ITEMS Patient-dependent (3-5 activities chosen by the patient) 20,32,55 
METHOD OF COLLECTION Written32,55 
TEST-RETEST RELIABILITY 
(Intraclass correlation coefficient 
2,1) 

Slight reliability:  
     0.17 (average)44 
Fair reliability:   
     0.59, CI95%:0.23-0.8146 
Moderate reliability:   
     0.71, CI95%:0.51-0.8453  
     0.73, CI:0.49-0.86 (Individual Activity 1),  
     0.75 CI:0.56-0.87 (Individual Activity 2)56 
Substantial reliability:  
     0.82, CI95%:0.54-0.9345 
     0.84, CI95%:0.78-0.8851 
     0.86, CI:0.74-0.93 (Individual Activity 3)56 
     0.87, CI95%:0.72-0.9457  
     0.91, p<0.0525 
     0.92, CI95%(lower limit):0.78 (average), 
     0.91, CI95%(lower limit):0.77 (Individual 

 Activities)58 
     0.9732 

VALIDITY (Pearson’s R)  0.77, CI95%:0.61-0.89, p<0.00251  
(Strong positive correlation) 

SEM 0.525 
0.4132  
1.545  
1.0346 
1.3, CI90% (individual activity); 0.62, CI90% (average score)51 
0.3557  

MDC 
1.425  
3.3, CI90% (average)44 
2.145 
3.446  
2.5 (individual activity); 1.5 (average score)51 
2.9, CI95%:1.7-4.253 
0.9757  
2.0 (individual activity)58  

Minimum Clinically Important Difference (all reported on average score) 
Low Back Pain 2.325 
Cervical Radiculopathy 2.244 

2.0 (Sensitivity 0.95, CI95%:0.77-0.92, Specificity 1.0, 
CI95%:0.82-1.0)45 

Spinal Stenosis 1.346 
Upper Extremity 1.2 (Sensitivity 0.88, Specificity 0.79)53 
Shoulder Complaint 1.2957 
Musculoskeletal Injuries 1.3, 2.3, 2.7 (small, medium, large change)59 

Average MCID (for average score based on these studies) is 2.1 
MCID for clinical use (based on Stratford’s original report): 2.0 average score; 3.0 for single activity 

score32,55  



Guidelines for Useful Integration of Patient-Rated Outcome Measures into Clinical Practice 

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Copyright © by Indiana State University         Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188   Volume 1 – Issue 2 – October 2018  

needs and priorities, further enhancing its 
applicability in athletic training practice. To be 
effective in improving patient care, PSFS scores 
from follow-up visits are compared to those on the 
initial administration of the scale.  

Disablement in the Physically Active Scale 
(Table 5, Appendix 324) 

 The Disablement in the Physically Active (DPA) 
scale was developed by athletic training 
researchers and is “derived from a disablement 
framework that includes measures of impairment, 
functional limitations, and disability.”24 The scale 
is multidimensional, incorporating measures that 
evaluate impairments, functional limitations, and 
disability.24  The DPA scale has enhanced value 
because it includes psychosocial measures.24 The 
DPA scale is an excellent tool to begin use of 
outcome measurement in clinical practice because 
it was developed specifically for and by athletic 
trainers. The format of the scale involves 16 
questions.24 Questions are rated on a scale of 1-
5, where 1 indicates that the patient does not 
have this problem and 5 indicates that the patient 

is severely affected by this problem.24 Scores for 
each question are added, then 16 is subtracted; 
thus the total score can range from 0-64 where 0 
indicates no dysfunction and 64 indicates severe 
dysfunction.24  

PRACTICAL USE OF PATIENT-RATED 
OUTCOME MEASURES  

Hankemeier et al.61 investigated the use of PROs 
in athletic training practice, finding that most 
respondents were unfamiliar with various PRO 
measures and rarely implemented them in 
practice. Their results were consistent with those of 
Valier et al,4 who reported that 26% of the 
athletic trainers responding incorporated PRO 
measures in patient care. Hankemeier et al.61 
proposed increased knowledge, behavioral 
change, organizational support, and professional 
responsibility to increase the use of PROs in 
athletic training practice. A central factor in the 
adoption of PROs in clinical practice is the 
intention to do so; the willingness and effort 
clinicians plan to exert.62 One method to increase 
knowledge about PROs is the publication of 

Table 5.  Psychometrics for Disablement in the Physically Active (DPA) Scale. 
PURPOSE Generic measure of health used in the evaluation of 

physically active individuals with musculoskeletal injuries 
measuring impairment, functional limitations, disability, 
and quality of life24,26,60  

GENERAL DESCRIPTION 6-item instrument with each response based on a 5-
point Likert scale from 1 (no problem) to 5 (severe).
Once scored, 16 points are subtracted from total score.
Score ranges from 0 to 64, with higher scores
representing lower levels of HRQoL status24,26,60 

METHOD OF COLLECTION Written24,26,27, 60 
TEST-RETEST RELIABILITY (Intraclass correlation 
coefficient 2,1) 

Moderate reliability: 
     0.7926 
Substantial reliability: 
     0.94, CI95%:0.89-0.9724 

VALIDITY (Pearson correlation) -0.75, p<0.001 (acute injuries)24

-0.71, p<0.002 (persistent injuries)24

(Strong negative correlation)
SEM 4.526 
MDC 12.4826 

Minimum Clinically Important Difference 
Acute Injuries 924 
Persistent injuries 624 
MCID for clinical use based on Vela & Denegar, 2010: 6 for persistent injuries, 9 for acute injuries24 



Guidelines for Useful Integration of Patient-Rated Outcome Measures into Clinical Practice 

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Copyright © by Indiana State University         Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188   Volume 1 – Issue 2 – October 2018  

easyto-use and read guidelines regarding 
specific PRO measures.  These publications may 
reduce clinicians’ burden in researching measures 
to use. Clinicians may be more likely to adopt the 
use of PROs in practice if they perceive a 
professional obligation to do so.62 Employer 
requirements, as well as National Athletic Trainers’ 
Association position statements, may help increase 
PRO collection in practice.61 Step-by-step 
guidelines to ease the adoption of PROs into use 
is necessary to support behavior change as well 
as knowledge. 

One practical guideline for adopting PROs into 
practice is to use measures that most likely reflect 
the effects of the athletic training intervention.63 
The NRS, a measurement of pain intensity, is 
routinely collected during history and can easily 
be transformed into an outcome measure by 
asking for NRS scores after intervention and 
across subsequent patient encounters. The PSFS 
scale to assess function can be adopted into the 
history portion of evaluation, then re-
administered after intervention and subsequent 
encounters. The clinician can use NRS and PSFS 
scores together to form a multifaceted 
understanding of the patient’s pain and function. 
After intervention, the GRoC is administered to 
gain understanding of the patient’s experienced 
change. Although all three of these measures can 
be printed to add to the patient’s file, they do 
not require pen and paper and are therefore 
easily administered during on-field evaluations, 
as well as in a clinic-based setting. The DPAS 
does require pen and paper, and can be 
administered while the clinician is preparing for 
the evaluation, then administered at regular 
intervals during the patient’s rehabilitation 
progression. Overall, the administrative burden 
in using these PROs is low. (See Table 6 for 
advantages and disadvantages of each PRO 
listed.) 

The following steps may be taken to adopt these 
PROs into clinical use: 

1. When possible, incorporate PROs into
electronic health record (EHR) platforms to
save time and improve direct care. 2,67 Some
scales have not been validated for electronic
use and scores may vary between paper
and electronic versions, so clinicians who
chose to incorporate PROs into electronic
format must switch between formats for a
given patient.

2. Use patient portals, tablets, or clinician
terminals to collect PROs such as the DPAS
before a visit or before beginning
evaluation,2,67 or have pen and paper
versions available at check in.  Alternatively,
DPAS forms may be kept with evaluation
form, SOAP notes, or near regularly used
evaluation tools (e.g. goniometers).

3. Use the most actionable, relevant PROs with
fewer than 30 questions.67 Together, the NRS
(current, best, worst, average), PSFS (3-5
specific activities), DPAS (16 questions), and
GRoC (1 question) include no more than 26
questions, most of which can be collected
during the routine history.

4. Incorporate NRS scores (best, worst,
average, current) and PSFS scores into
standard evaluation and rehabilitation
documents (e.g. flow sheets).

5. Make the PROs relevant to the patient by
reviewing the patient’s responses in real time
and asking follow up questions as part of the
evaluation. 2,67

6. Create a sheet with MCIDs for all four PROs
or print out accompanying tables.

7. Evaluate patient flow through the athletic
training clinic for each clinician to identify key
personnel involved in and appropriate timing
for the administration of PROs.2,3 When all
staff members are committed to the collection
of PROs, they can work together to determine
the best point of collection, analysis, and
integration into patient encounters.3



Guidelines for Useful Integration of Patient-Rated Outcome Measures into Clinical Practice 

23 
Copyright © by Indiana State University         Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188   Volume 1 – Issue 2 – October 2018  

PRACTICE IMPLICATIONS 

The consensus in the literature indicates each of 
these PRO measures may be used in conjunction 
with other generic measures as well as specific 
measures related to the patient’s injury. Both the 
DPAS and the PSFS are developed specifically 
for the patient population treated by athletic 
trainers and are therefore most applicable. 

As novice PRO users adopt these measures into 
their practice, individual patient care will likely 
improve as they become more competent and 
comfortable with their use. Clinicians may 
improve their practice using the information 
gleaned in regular PRO measurement. Once the 
athletic trainer becomes adept at the use of 
these generic measures, more specific measures 
may be integrated as appropriate. 

Table 6:  Advantages and Disadvantages of Specific Generic PROs. 
ADVANTAGES DISADVANTAGES 

NRS Commonly used15,17,33  
Simple to score15,34,37  
Quick38  
Easy to administer and 
record15,30,34,36-38  
Individuals who are older or less 
literate, or have sustained trauma or 
lack intact motor skills, can easily 
complete the scale35,36,38 

Only measures one dimension (intensity) of a 
multifaceted, complex, and contextual 
symptom15,30  
Has less ability to detect change than self-
reported functional measures35  

GRoC Quick22 
Applicable to wide ranges of patient 
populations22 
Easy to understand22 
Strong clinical relevance22 
Adaptable22,31  
Measures deterioration as well as 
improvement22  

Relies on patient’s estimates of previous health 
status22,31,48  
Patients may demonstrate recall bias (basing 
previous health status on current status)22,31,48 
Scores may fluctuate with repeated measure48  
Only correlated to functional measures up to 3 
weeks48  

PSFS Patient specific20,32, 51,55,64  
Fast and Efficient20,51,55  
Easy to use20,32,65  
Able to assess important change over 
time32  
Formalizes questions asked during 
routine evaluation32,66  
Aids clinicians in planning treatments 
and evaluating progress51,55,64 
Applicable to a variety of clinical 
presentations and demographic 
populations58  

Difficult to compare between patients20,53,54,58 
Little range available on the scale for patient 
to describe decreased ability when condition 
deteriorates51  

DPAS Specifically designed for use among 
the physically active24, 27,26,60  
Includes 4 important dimensions of 
HRQoL (impairment, functional 
limitations, disability, quality of life)24 

Scale is new (developed in 2010)24 
Lacks clinimetric support24,26,27,60  



Guidelines for Useful Integration of Patient-Rated Outcome Measures into Clinical Practice 

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Copyright © by Indiana State University         Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188   Volume 1 – Issue 2 – October 2018  

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Guidelines for Useful Integration of Patient-Rated Outcome Measures into Clinical Practice 

29 
Copyright © by Indiana State University         Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188   Volume 1 – Issue 2 – October 2018  

Appendix 1. Global Rating of Change (GROC)

Patient Name/Number:   

Date: 

Global Rating of Change Scale (GROC) 

Please rate the overall condition of your shoulder from the time that you began treatment until now 
(check only one): 

A very great deal worse (-7) 
A great deal worse (-6) 
Quite a bit worse (-5) 
Moderately worse (-4) 
Somewhat worse (-3) 
A little bit worse (-2) 
A tiny bit worse (-1) 

About the same (0) A very great deal better (7) 
A great deal better (6) 
Quite a bit better (5) 
Moderately better (4) 
Somewhat better (3) 
A little bit better (2) 
A tiny bit better (1) 

Jaeschke R, Singer J, Guyatt GH. Measurement of health status. Ascertaining the minimal clinically 
important difference. Control Clin Trials 1989: 407-415. 



Guidelines for Useful Integration of Patient-Rated Outcome Measures into Clinical Practice 

30 
Copyright © by Indiana State University      Clinical Practice in Athletic Training 

All rights reserved. ISSN Online 2577-8188   Volume 1 – Issue 2 – October 2018 

Appendix 2. Patient-Specific Functional Scale (PSFS) 

The Patient-Specific Functional Scale 
This useful questionnaire can be used to quantify activity limitation and measure functional outcome for patients 
with any orthopaedic condition. 

Clinician to read and fill in below: Complete at the end of the history and prior to physical examination. 

Initial Assessment: 
I am going to ask you to identify up to three important activities that you are unable to do or are having difficulty 
with as a result of your  problem. Today, are there any activities that you are unable to do 
or having difficulty with because of your  problem? (Clinician: show scale to patient and have the patient rate each 
activity). 

Follow-up Assessments: 
When I assessed you on (state previous assessment date), you told me that you had difficulty with (read all 
activities from list at a time). Today, do you still have difficulty with: (read and have patient score each item in the 
list)? 
Patient-specific activity scoring scheme (Point to one number): 

0 1 2 3 4 5 6 7 8 9 10 

Unable to perform activity 

 (Date and Score) Able to perform activity at the 
same level as before injury or 
problem 

Total score = sum of the activity  scores/number  of  activities  Minimum detectable change (90%CI) for average 
score = 2 points Minimum detectable change (90%CI) for single activity score = 3 points 
PSFS developed by: Stratford, P., Gill, C., Westaway, M., & Binkley, J. (1995). Assessing disability and change on 
individual patients: a report of a patient specific measure. Physiotherapy Canada, 47, 258-263. 
© P Stratford 1995, reprinted with permission.

Activity Initial 
1. 
2. 
3. 
4. 
5. 
Additional 
Additional 



PATIENT-CENTERED CARE COMMENTARY 

31 
Copyright © by Indiana State University         Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188   Volume 1 – Issue 2 – October 2018 

Appendix 3. Disablement in the Physically Active Scale   (DPA) Scale




